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Pearls


Better psychiatric documentation: From SOAP to PROMISE

Vol. 12, No. 03 / March 2013

Discuss this article at www.facebook.com/CurrentPsychiatry

Because documentation is an important part of medical practice,1 numerous tools have been developed to help physicians across all specialties, including the best-known acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. The SOAP note has been used in mental health settings,2 although this format may fall short for psychiatrists because objective tests are not diagnostic. Also, there’s no clear guidance to document specific information, such as behavioral risk assessment.

The acronym PROMISE—Problems, Resolved, Outcomes, Medications, Instructions, Safety, and Education—may be better suited for psychiatric documentation. The PROMISE note provides an easy-to-remember method to document specific information that might be overlooked in a less detailed format, such as normal findings, adherence and tolerability to medications, outcome ratings, and risk assessment.

Problems are described as ongoing symptoms, signs, and stressors. Resolved indicates improvement and normal findings. Outcome measures include patient or clinician rating scales. Medications documents the effectiveness and tolerability of current and past medications. Instructions are directives given; the rationale—cost-benefit analysis—can be documented in this section as well. Safety describes a behavioral risk assessment, including demographic, historical, clinical, and environmental risk and protective factors regarding suicidal or homicidal behavior. Education describes the verbal or written material shared with the patient.

Psychotherapists can use the same template. For them the M would stand for Methods of psychotherapy practiced in the session.

For an example of the PROMISE note used in practice, see the Table.

Table

Example of a patient’s PROMISE note

Problems

Ongoing depressive symptoms: low mood, negative thinking, low interest level; patient has no insurance, pays out of pocket

Resolved

Mild improvement in motivation noted; sleeping and concentration both OK; continues to work full-time; spends time with parents

Outcomes

Clinical Global Impression-Severity Scale score: 4; PHQ-9 depression rating scale score: 12/27, indicating moderate depression (score 1 month ago was 15/27; 20% reduction)

Medications

Current treatment: citalopram, 20 mg/d, nortriptyline, 50 mg/d

Prior medications: bupropion, citalopram, clomipramine, fluoxetine, MAOIs, sertraline, and venlafaxine. Patient’s adherence to medication is good

Tolerability issues: sweating, constipation, dry mouth

Instructions

Increase both medications (20% improvement noted; recommend increase in nortriptyline; patient requests increase in citalopram). Ongoing moderate depression; initial side effects may subside

Safety

Identified risk or protective factors for suicidal, aggressive, or homicidal behavior: chronic depression without remission

No current SI, HI, SIB, hopelessness, anxiety, agitation, insomnia, substance use, psychosis, or interpersonal aggression. No access to weapons. No history of suicide attempts. Good supports. Risk assessment: low

Education

  1. What is the main problem? Chronic unremitting depression, some mild side effects—eg, dry mouth, constipation
  2. What can the patient do about it? Optimize meds; exercise (30 minutes of fast walking per day); increase fiber in diet
  3. Why is it important to do this? Achieve remission (PHQ-9 score: <4); improve tolerability

HI: homicidal ideation; MAOIs: monoamine oxidase inhibitors; PHQ-9: 9-Question Patient Health Questionnaire; SI: suicidal ideation; SIB: self-injurious behavior

Disclosure

Dr. Bastiaens reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Gutheil TG. Fundamentals of medical record documentation. Psychiatry (Edgmont). 2004;1(3):26-28.

2. Cameron S, Turtle-Song I. Learning to write case notes using the SOAP format. J Couns Dev. 2002;80(3):286-292.

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