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PCBH FAQ - Documentation
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How are behavioral health consult appointments/medical team consultations documented in the medical record?
Author: Suzanne Daub

A cornerstone of integrate care is that documentation of physical and behavioral health care resides in the medical record. Many PCBH programs have adopted the Subjective, Objective, Assessment, Plan (SOAP) note format because it mirrors the documentation format used in primary care.  Good SOAP notes reflect integrative thinking.  This means not just reporting details but combining them into a coherent whole that frames the information in a functional way.  This is done through connecting symptoms, severity and events. 1  The BHC is relating the data the patient gave (Subjective)) and combining it with objective data (Objective), integrating these into a coherent understanding of what is keeping this patient from functioning (Assessment) and producing a plan based on these factors (Plan).  The SOAP notes are also written with consideration for inclusion of only the relevant data related to that person's ongoing care, omitting irrelevant or unnecessary data that might be included in broader specialty mental health records.  Generally the following elements are present in the behavioral health consultant SOAP note.

Subjective:

  • Referred by
  • Reason for Referral
  • Chief Complaint Today
  • Presenting Symptoms
  • Severity of Symptoms
  • Chronicity of Symptoms
  • Prior Treatment History
  • Mitigating Factors

Objective

  • Orientation (#3, cognition, speech)
  • Appearance
  • Affect
  • Suicidal/Homicidal ideation
  • Substance Abuse
  • Medications (psychotropic meds, adherence)
  • Test results of any mental health measures used

Assessment:

  • Provisional Diagnosis
  • Motivation and State of Change
  • Key Area for Intervention
  • Clinician Assessment of Progress or lack thereof on follow-up notes

Plan

  • Recommendations to the PCP
  • Follow-up Date (if applicable)

Serrano, N. (Ed.)(2014) The Implementer's Guide to Primary Care Behavioral Health

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