Patient wellbeing assessment and recovery plan – SOAP 	
Notes: This form is designed for use with the following Medicare Benefits Schedule (MBS) items. Users should be familiar with the most recent item definitions and requirements. 
MBS item number:    2700     2701     2715     2717    
This document is not a referral letter. A referral letter must be sent to any additional providers involved in this Mental Health Treatment Plan.
Major headings are bold; prompts to consider lower case. Response fields can be expanded as required. Underlined items of either type are mandatory for compliance with Medicare requirements.	
Contact and demographic details	
GP name		GP phone		
GP practice name		GP fax		
GP address		Provider number		
Relationship	This person has been my patient since		
	and/or	
	This person has been a patient at this practice since		
Patient surname		Date of birth (dd/mm/yy)	
	
Patient first name/s		Preferred name		
Gender	 Female    Male    Self-identified gender:	
Patient address		
Patient phone	Preferred number:

Can leave message?    Yes     No	Alternative number:

Can leave message?    Yes     No	
Medicare no.		Health Care Card/Pensioner Concession Card  no.		

Carer/support person contact details 	Has patient consented for this healthcare team to contact carer/support persons?	
First contact:	Relationship:	Phone number 1:

Phone number 2:

	 Yes

With the following restrictions:
	 No	
Second contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes

With the following restrictions:
	 No	
Emergency contact person details	Patient consent for healthcare team to contact emergency contacts?	
First contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes	 No	
Second contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes	 No	
Salient communication and cultural factors	
Language spoken at home	 English	 Other:	
Interpreter required	 No	 Yes, comments:	
Country of birth	 Australia	 Other:	
Other communication factors		
Other relevant cultural factors		

S – ‘Subjective’	
Consider:
•	Reasons for presenting
•	History of current episode
•	Mental health history
•	Salient social history
•	Salient medical/biological history
•	Salient developmental issues
•	Family history of mental illness/suicidal behaviour
•	Current domestic and social circumstances, including relationships and occupation
•	Salient substance use issues
•	Current and previous medications, including effectiveness and side effects for mental disorders.

	

O – ‘Objective’	
Comments on current mental state examination

Consider:
•	Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
•	Appropriateness of Mini-Mental State Examination (MMSE) for patients aged ˃75 years or if otherwise indicated

Allergies		
Relevant physical examination and other investigations		
Results of relevant previous psychological and developmental testing		

A – ‘Assessment’	
Risk assessment – 
If high level of risk indicated, document actions taken in the treatment plan below

Consider asking:
•	Does the patient have a timeline for acting on a plan?
•	How bad is the pain/distress experienced?
•	Is it interminable, inescapable, intolerable?		Ideation/ thoughts	Intent	Plan	
	Suicide	
			
	Self-harm	
			
	Harm to others	
			
	Comments or details of any identified risks	
		
Assessment/outcome tool used (except where clinically inappropriate)

Include:
•	Date of assessment
•	Results

		
Case formulation and provisional diagnosis of mental health disorder

Consider asking about:
•	Predisposing factors
•	Precipitating factors
•	Perpetuating factors
•	Protective factors

Consider conditions specified in the International Classification of Primary Care, 2nd edition

	

P – ‘Plan’	
Patient goals
Setting personal recovery Goals

Also consider:
•	The person themselves prioritising the goal/s to focus on 
•	The CHIME framework: connectedness, hope, identity, meaning and purpose, and empowerment
•	Which strengths are relevant and can be built on to pursue goal/s 
•	How the person’s values, treatment and support preferences will impact on the action plan 
•	Breaking goals down into smaller manageable steps and making plans for who will do what and when – informally or using the SMART (specific, meaningful, attainable, realistic, timetabled) approach
•	Supporting the person to undertake independent or joint actions rather than accepting passive actions

	

	
Treatments and interventions

Consider:
•	Suggested psychological interventions
•	Medications
•	Key actions to be taken by patients
•	Support services to achieve patient goals
•	Role of GP
•	Psycho-education
•	Time frame
•	Internet-based options:
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack 
		
Referrals

Consider:
•	Practitioner, service or agency – referred to whom, and for what
•	Specific referral request
•	Opinion, planning, treatment
•	Case conferences
•	Time frame
•	Referral to internet mental health programs for education: 
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack

Role of carer/support person		
Intervention/relapse prevention plan
(if appropriate at this stage)

Consider asking about:
•	Warning signs from past experiences
•	Arrangements to intervene in case of relapse or crisis
•	Support services currently in place
•	Any past effective strategies

Other healthcare providers and service providers involved in patient’s care
(eg psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case worker, community mental health services)	
Role	Name	Address	Phone	

	
Completing the plan  
	
On completion of the plan, the GP may record (tick boxes below) that they have:

  Discussed the assessment with the patient
  Discussed all aspects of the plan and the agreed date for review
  Offered a copy of the plan to the patient and/or their carer (if agreed by patient)
	Date plan completed	
		
Plan added to the patient’s records?	  Yes
  No	
Copy of the plan offered to other providers?	  Yes
  No
  Not required	

Record of patient consent	
I, ___________________________________________________[name of patient], agree to information about my health being recorded in my medical file and being shared between the GP and other healthcare providers involved in my care, as nominated above, to assist in the management of my healthcare. I understand that I must inform my GP if I wish to change the nominated people involved in my care.  
I understand that as part of my care under this Mental Health Treatment Plan, I should attend the general practice for a review appointment at least four weeks, but no longer than six months, after the plan has been developed.
I consent to the release of the following information to the following carer/support and emergency contact persons:	
Name	Assessment	Treatment Plan	
	Yes	No	Yes	No	
	 With the following limitations:
	
	 With the following limitations:

	 With the following limitations:
	
	 With the following limitations:

__________________________________________
Signature of patient	
________/________/________
Date	

I, ________________________________________, have discussed the plan and referral/s with the patient.
Full name of GP	
Mental Health Treatment Plan Included:                                                          

__________________________________________
Signature of GP	      No          Yes (if yes, please select below)
                        MBS item number:  
                         2700     2701     2715   2717    

_______/________/________
Date	

Request for services

Date: 

To:
[Attn]
[Address]
[Post code]

Subject: Letter of request for services

Dear Dr

I am referring [patient’s name] for 

I am referring [patient’s name] [date of birth] for [number of sessions] sessions.

I have been [patient’s name]’s primary care physician for the past [number of years] years.

In summary, the following assessment and treatment planning has been undertaken: [  ]

Mental Health Treatment Plan attached:  Yes  No

Specific treatment requests: [  ]

If you have any questions, please feel free to contact me directly. I will be available on phone [T+00000000] and email [email@email.com] in case of any query.

Looking forward to your reply.

Yours sincerely,

[Signature]	
			
[Physician’s name and title]

[Provider number]

	

Review	
MBS item number:    2712     2719	
Planned date for review with GP
(Initial review four weeks to six months after completion of plan)
		
Actual date of review with GP
		
Assessment/outcome tool results on review (except where clinically inappropriate)

Comments – review of patient’s progress against goals, checking, reinforcing and expanding education, modification of treatment plan (if required)
		
Intervention/relapse prevention plan (if appropriate)