In pediatric psychology, comprehensive SOAP (Subjective, Objective, Assessment, Plan) notes are essential for maintaining accurate patient records. These notes not only document patient interactions but also aid in continuity of care and legal compliance. Here’s a step-by-step guide on how to effectively write and format clinical documentation using a specific template.

Example SOAP Note for Pediatric Psychology

Visit Title: Anxiety and School Performance

Chief Complaint:

The patient states, "I'm feeling overwhelmed and anxious about school."

HPI/Interim History:

The patient, a 15-year-old female, reports increased anxiety over the past three months, particularly related to academic performance. She denies any substance use. The anxiety is impacting her ability to concentrate and complete assignments, leading to a decline in grades. She has not required a leave of absence but is concerned about her academic future.

Psychotherapy and Psychotherapeutic Interventions:

180 minutes spent on therapy focusing on anxiety management. Discussed coping strategies for school-related stress and time management. Utilized cognitive-behavioral therapy (CBT) and mindfulness techniques, which the patient found helpful. Target symptoms include anxiety and stress, with moderate improvement in managing anxiety. Techniques used are CBT and mindfulness.

Current Medications Discussed:

Sertraline 50 mg daily: Effective with mild side effects of drowsiness, good adherence. No changes to medications.

Pertinent Past Medications and Psychiatric Treatments:

Previously trialed fluoxetine with limited efficacy. No history of TMS, ECT, or other advanced treatments. No past psychiatric hospitalizations.

Objective:

Mental Status Exam:

• General Appearance and Behavior: Well-groomed, cooperative

• Motor abnormalities: No abnormal motor movements

• Speech: Normal rate, rhythm, and prosody

• Eye contact: Consistent

• Affect: Congruent, anxious

• Mood: "Anxious"

• Thought content: Preoccupied with academic performance

• Thought process: Linear and goal-directed

• Cognition: Grossly intact attention and memory

• Orientation: Alert and oriented

• SI, HI, Violent ideation: Absent

• Insight and judgment: Good insight, fair judgment

DATA (billed):

GAD-7 completed, score: 15 (moderate anxiety). No labs or other studies referenced.

Clinical Global Impressions:

CGI-S (Severity): 4 (Moderate) - Due to significant anxiety impacting daily functioning. CGI-I (Improvement): 3 (Minimal improvement) - Some progress with therapy and medication.

Assessment and Plan:

Generalized Anxiety Disorder: Moderate anxiety impacting school performance, continue CBT and sertraline. Academic Stress: Addressed through therapy, continue monitoring. Overall: Patient shows moderate improvement, continue current treatment plan.

Risk Assessment:

No current concerns for self-harm or violence. Protective factors: Supportive family, engaged in therapy. Risk factors: Academic stress, anxiety. No escalation of care needed.

Medication and Interventions Plan:

Continue sertraline 50 mg daily. Discussed risks and benefits of medication, patient and family in agreement. No new research studies mentioned.

Tests and Studies:

No tests or studies ordered.

Collaboration Plan:

Coordinating with school counselor for academic support. Family involved in therapy sessions. No additional collateral information needed.

Medical Decision Making:

Considered patient's academic stress and anxiety levels. E/M Code: 99214 (Established patient, moderate complexity) - Due to moderate complexity of anxiety management.

Interactive Complexity Present:

Not applicable.

Followup:

Next appointment scheduled for 15 November 2024. No discharge plan needed.

As healthcare professionals strive to deliver quality care, documentation remains a time-consuming task. Here, AI medical scribes like Notis AI Medical Scribe come into play, revolutionizing the documentation process in pediatric psychology.

Notis AI Medical Scribe is designed to streamline documentation by transforming voice interactions into structured SOAP notes. This tool significantly reduces the time spent on administrative tasks, allowing pediatric psychologists to focus more on patient care. With features like high transcription accuracy, ease of use through WhatsApp, and multilingual support, Notis ensures efficient and accurate patient charting.

By integrating AI medical scribes into your practice, you can save valuable time, improve the quality of clinical notes, and enhance overall patient care. This transition not only boosts productivity but also reduces burnout, making it a valuable asset for any pediatric psychology practice.