Docs/Tom.txt

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: Meet with Tom again in 2 days, Friday, 20th May. Tom to follow his safety plan if required. Tom to make his family aware of his current state of mind. Refer Tom to a mental health professional for further assessment and treatment.

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: 1. Meet with Tom again in 2 days, Friday, 20th May; 2. Tom to follow his safety plan if required; 3. Tom to make his family aware of his current state of mind; 4. Refer Tom to a mental health professional for further assessment and treatment; 5. Run 5 times a week.

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: 1. Meet with Tom again in 2 days, Friday, 20th May 2. Tom to follow his safety plan if required 3. Tom to make his family aware of his current state of mind 4. Refer Tom to a mental health professional for further assessment and treatment.

Doctor: 
Patient: Tom
General: 
Subjective
Martin reports that his depressive symptoms have worsened and are more frequent and intense. He feels fatigued both mentally and physically, has difficulty concentrating, and quickly becomes irritated. He also experiences feelings of worthlessness and self-loathing. Martin denies any hallucinations, delusions, or other psychotic-related symptomatology and his compliance with medication is good. He has lost weight and has a diminished interest in food and a decreased intake.

Objective
Martin appears listless, distracted, and minimally communicative. His speech is normal in rate, volume and articulation is coherent and spontaneous. Language skills are intact. There are signs of severe depression. Body posture, eye contact, and attitude portray a depressed mood. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Martin is fully orientated. Martin's behavior in this session was cooperative and attentive.

Assessment
Martin presents with severe depression and requires ongoing treatment and support.

Plan
1. Meet with Martin again in 2 days, Friday,

Doctor: 
Patient: Tom
General: 
A SOAP note is a structured format for documenting a patient's medical or clinical status. It is an acronym for Subjective, Objective, Assessment, and Plan. The subjective section includes the patient's reported symptoms and concerns. The objective section includes the clinician's observations and measurements. The assessment section includes the clinician's diagnosis and treatment recommendations. The plan section includes the clinician's instructions for follow-up care.

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: 1. Meet with Tom again in 2 days, Friday, 20th May; 2. Tom to follow his safety plan if required; 3. Tom to make his family aware of his current state of mind; 4. Refer Tom to a mental health professional for further assessment and treatment; 5. Monitor Tom's symptoms and progress regularly; 6. Provide psychoeducation and support to Tom and his family.

Subjective: Tom reports that his depressive symptoms have worsened and are more frequent and intense. He feels fatigued both mentally and physically, has difficulty concentrating, and quickly becomes irritated. He also experiences feelings of worthlessness and self-loathing. Tom denies any hallucinations, delusions, or other psychotic-related symptomatology and his compliance with medication is good. He has lost weight and has a diminished interest in food and a decreased intake.
Objective: Tom appears listless, distracted, and minimally communicative. His speech is normal in rate, volume and articulation is coherent and spontaneous. Language skills are intact. There are signs of severe depression. Body posture, eye contact, and attitude portray a depressed mood. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Tom is fully orientated. Tom's behavior in this session was cooperative and attentive.
Assessment: Tom presents with severe depression and requires ongoing treatment and support.
Plan: 1. Meet with Tom again in 2 days, Friday, 20

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: 1. Meet with Tom again in 2 days, Friday, 20th May; 2. Tom to follow his safety plan if required; 3. Tom to make his family aware of his current state of mind; 4. Refer Tom to a mental health professional for further assessment and treatment.

Subjective: Tom reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: Tom appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic.
Assessment: Tom appears to be suffering from major depressive disorder. His symptoms are severe and are interfering with his day-to-day functioning.
Plan: 1. Meet with Tom again in 2 days, Friday, 20th May; 2. Tom to follow his safety plan if required; 3. Tom to make his family aware of his current state of mind; 4. Refer Tom to a mental health professional for further assessment and treatment.