Sample SOAP Note

Problem: Visual Hallucinations & Self Care Deficit.

S - Patient states, " I see white winged unicorns, white winged unicorns come
from my body and give me a warm feeling." "I am a beardless Jesus, with the sun
over me and I get this warm feeling; I like white winged unicorns." Pt reports
feeling a little tired.

O - Pt is awake, but drowsy his speech is slow, and his affect is elated when
talking about "white winged unicorns." but otherwise flat. He is slowly pacing
back and forth in the hallway talking and smiling to himself at times . He is
pleasant, calm on approach but is generally isolative. He is unkempt, unshaven,
wearing soiled sweat pants, torn shirt and flip flops. Vitals signs and labs are
normal. He denies command hallucinations suicidal/homicidal thoughts, intent or
plans. Appetite remains good. Pt attended all unit activities with limited
participation and is cooperative with medical regimen.

A- Patient is responding to internal stimuli, experiencing visual and tactile

hallucinations and somatic delusions with mild anxiety evidenced by his pacing. Pt
is experiencing self care deficit and altered sense of reality and poor insight and
judgment at this time.

P - Assist pt with hygiene and grooming (ADL) encourage adequate rest, maintain
safety. Observe for changes in behavior, mood and affect. Continue current
medical regimen and medicate PRN for anxiety and hallucinations.