SOAP Notes and Record Keeping in Mental Health Care: An Overview

This report provides a comprehensive overview of SOAP notes and record-keeping practices within mental health care, particularly focusing on the perspective of an occupational therapist. It emphasizes the crucial role of patient documentation in ensuring continuity of care, effective communication among healthcare professionals, and proper medical billing. The report details the four key components of SOAP notes: Subjective (patient's chief complaints and history), Objective (therapist's assessment and observations), Assessment (diagnosis of the patient's mental state), and Plan (treatment strategies and goals). It highlights the importance of accurate and detailed record-keeping for the constant review of the patient's condition, adherence to appropriate care, and informed decision-making, ultimately improving patient outcomes. The report references key literature to support the significance of these practices in the field of mental health.

SOAP notes and Record Keeping in Mental Health Care
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Introduction
SOAP notes taking is a crucial documentation method utilized in the health care arena in
writing down patients data along with other common data input formats such as admission
sheets. Patient documentation in the health care arena is essential and formal a key
fundamental practices guide which ensures that there is flow of patent information from
admission, treatment m management to medical billing and follow up procedures (Harrison,
2017). SOAP notes are essential in medical records used by various health care personnel to
initiate patient communication processes and monitor the patients and appropriate follow-up.
Medical records are essential in providing high-quality care to the patients. SOAP notes
process has been utilized in health care practice especially in acute mental health and forms a
fundamental aspect towards mental health services (Ferri, 2014).
The fundamental key component of SOAP notes entails subjective, objective, assessment and
plan management process. As an occupational therapist nurse, SOAP notes taking are
essential in various perspectives. The subjective perspective of patient's take place in the form
of chief complains. This entails a brief statement of the patient on the purpose of the visit.
During a mental health initial assessment, history of the patient is undertaken. This elaborates
the state of the patient in a more realistic and narrative form. The state of the mental health
patient is recorders as per the patient own words and communicated to the mental health
therapists (Ingram, 2011).
The underlying negative symptoms are considered diligently. The overall medical history if it
exists is identified and other related events such as medication, lifestyle status, allergies, and
other side effects if any are recorded. Other variables which in documenting the patient state
entails recording of onsets, location type, aggravating factors, radiation factors, temporal
patterns and severity state of the patients are recorded (Oudshoorn & Sinclair, 2015).

Underlying objective assessments for the patient are undertaken. Objective information for
the patient entails the mental health therapists' assessment of the current status which entails
vital signs, assessment on normal and abnormal behavior patterns and other diagnostic tests if
available. The objective assessment entails the overall functioning of the patient body and the
state of the neurological state. Direct observation of the patient is undertaken at this stage,
factual information of the patient is undertaken. The measurable data of the patient such as
the vital signs, tests scores and observations are undertaken and noted down. A preview of
the patient is undertaken based on the overall cognitive, psychological and emotional state of
the patients. This assessment is critical for identifying factors or contrary information which
can contradict information on the subjective findings of the patient (Mitsuishi et al., 2016).
Assessment stage of SOAP note taking entails the general diagnosis of the patient mental
state. This depicts a single diagnosis which is dependable on the information obtained from
the lab's tests and other definitive lab tests. This provides an up to date information for the
patient. This offers the likely etiological factors pertaining to the patient and needs of therapy
care and currently available therapy sessions.
During the planning stage, mental health assessment necessitates developing a plan of action
for the patient. Further medical assessment s can be undertaken at this juncture. This process
describes the causes of treatment and highlights deficits in the overall assessment. The
fundamental plan is to set a clear road map of the overall patient plan on the course of
treatments. This plan reflects the assessment undertaken for the patients. The plan identified
in this stage entails an address on the goal of the therapy and drug management which is
specific to the patient state. The strategy to management patient mental state is undertaken at
this stage with proper medical record undertaking improves follow up management of the
patient state (Pearce, Ferguson, George & Langford, 2016).

Conclusion
Analysis of patient mental state assessment in mental care services using SOAP style is
essential in documenting the patient state and current condition and treatment progress.
Effective notes are essential in providing effective documentation which allows therapist
health care staff to implement through acceptable standards of care, which utilizes
appropriate interventions and illustrate these interventions which disposes of the patient case.
Documenting this information is crucial in the overall medical history of the patient.
Appropriate record keeping allows for constant review of the patient and adherence to
appropriate care provisioning which ensures constant review of the patient status. thus as an
occupational therapist, utilization of SOAP and record keeping is essential in the overall
nursing practices as it ensures constant review and appropriate decision making for patient
care.

References
Ferri, F.F., 2014. Ferri's Clinical Advisor 2015 E-Book: 5 Books in 1. Elsevier Health
Sciences.
Harrisson, S., 2017. Nursing Progress Notes in Psychiatry: Mental Health Archival Data.
Sante mentale au Quebec, 41(2), pp.69-82.
Ingram, B.L., 2011. Clinical case formulations: Matching the integrative treatment plan to
the client. John Wiley & Sons.
Mitsuishi, F., Young, J.Q., Leary, M., Dilley, J. and Mangurian, C., 2016. The Systems
SOAP Note: A Systems Learning Tool. Academic Psychiatry, 40(1), pp.164-171.
Oudshoorn, A. and Sinclair, B., 2015. Using unfolding simulations to teach mental health
concepts in undergraduate nursing education. Clinical Simulation in Nursing, 11(9), pp.396-
401.
Pearce, P.F., Ferguson, L.A., George, G.S. and Langford, C.A., 2016. The essential SOAP
note in an EHR age. The Nurse Practitioner, 41(2), pp.29-36.