Schizophrenia SOAP Note Example: Complete Guide for PMHNP Students (NRNP 6675 Week 5)

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Schizophrenia SOAP Note Example

Quick Overview: A schizophrenia SOAP note documents a psychiatric patient’s subjective complaints, objective clinical findings, assessment (diagnosis using DSM-5-TR criteria), and treatment plan. For NRNP 6675 Week 5, your SOAP note must include a full mental status exam, evidence-based medication management rationale, and legal/ethical considerations formatted in APA 7.

If you are enrolled in Walden University’s NRNP 6675 or any PMHNP program, the Week 5 schizophrenia SOAP note is one of the most clinically demanding assignments you will face. The note requires you to integrate DSM-5-TR diagnostic criteria, pharmacological reasoning, and patient-centered care into a single, structured document.

This guide breaks down every section of a psychiatric SOAP note for schizophrenia spectrum disorders, provides a full annotated example, and explains exactly what graders look for. Whether you need to understand the format, check your work, or see a complete model note, this is the only resource you need.

What Is a Schizophrenia SOAP Note?

A schizophrenia SOAP note is a structured clinical documentation tool used by psychiatric-mental health nurse practitioners (PMHNPs) to record patient evaluations for schizophrenia spectrum and other psychotic disorders.

SOAP stands for Subjective, Objective, Assessment, and Plan. Each section captures a distinct layer of the clinical encounter, from what the patient reports to what the clinician observes, diagnoses, and prescribes.

For academic purposes, especially in PMHNP programs like Walden’s NRNP 6675, the SOAP note is the primary vehicle for demonstrating clinical reasoning. Graders assess whether you correctly apply DSM-5-TR diagnostic criteria, select evidence-based treatments, and document ethical and legal considerations.

Understanding Schizophrenia Spectrum Disorders Before You Write

Schizophrenia spectrum disorders include schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and delusional disorder, all classified under the same diagnostic umbrella in the DSM-5-TR.

Before writing your SOAP note, you must understand the core diagnostic criteria for schizophrenia (DSM-5-TR 295.90 / F20.9):

Criterion A: Two or more of the following for at least one month: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms
Criterion B: Significant functional decline in work, relationships, or self-care
Criterion C: Continuous signs for at least six months
Criterion D: Exclusion of schizoaffective disorder and mood disorders
Criterion E: Not attributable to substances or another medical condition
Criterion F: No history of autism spectrum disorder unless delusions/hallucinations are prominent

You must document which criteria are met directly in the Assessment section of your SOAP note. Vague statements like ‘patient has schizophrenia’ will not satisfy your rubric.

How to Write Each Section of a Psychiatric SOAP Note for Schizophrenia

S — Subjective: What the Patient Reports

The Subjective section documents the patient’s own account of their symptoms, history, and current concerns as reported during the clinical interview.

This section should include:

Chief complaint in the patient’s own words (use quotation marks)
History of present illness (HPI): onset, duration, frequency, severity, and context of psychotic symptoms
Positive symptoms reported: auditory/visual hallucinations, paranoid ideation, thought insertion/broadcasting, delusions
Negative symptoms reported: flat affect, avolition, alogia, anhedonia
Medication history: current psychotropics, adherence, reported side effects
Psychiatric history: prior hospitalizations, previous diagnoses, prior treatment responses
Substance use history (critical differential for psychosis)
Family psychiatric history
Review of systems relevant to psychiatric medications (e.g., metabolic syndrome screening for antipsychotics)

Clinical Tip: Always document the patient’s exact words for their chief complaint. For example: ‘The voices tell me my neighbors are watching me through the walls.’ This level of specificity is what distinguishes an advanced practice clinician from a student note.

O — Objective: What You Observe and Measure

The Objective section contains your empirical clinical findings, including the mental status examination (MSE), vital signs, current medications with doses, and any relevant lab results.

For schizophrenia SOAP notes, the Mental Status Exam is the centerpiece of the Objective section. Document all MSE domains:

Appearance: Grooming, dress, hygiene, eye contact, psychomotor activity
Behavior/Attitude: Cooperative, guarded, hostile, bizarre
Speech: Rate, rhythm, volume, latency, coherence
Mood: Patient-reported, in quotes (e.g., ‘I feel fine’)
Affect: Flat, blunted, restricted, labile, congruent/incongruent with mood
Thought Process: Linear, tangential, circumstantial, loose associations, thought blocking, flight of ideas
Thought Content: Paranoid ideation, ideas of reference, delusions (somatic, grandiose, persecutory), suicidal/homicidal ideation
Perceptions: Auditory/visual/tactile hallucinations; document command hallucinations explicitly
Cognition: Orientation x4, memory (recent and remote), concentration, abstraction
Insight: Full, partial, or absent insight into illness
Judgment: Intact, impaired, based on hypothetical scenario

Include current medications with doses, routes, and frequencies. For antipsychotics, document the last date of a long-acting injectable (LAI) if applicable. Note relevant labs such as metabolic panel, prolactin, CBC, and lipid panel where relevant to medication monitoring.

A — Assessment: Your Clinical Diagnosis

The Assessment section is where you demonstrate your diagnostic reasoning by applying DSM-5-TR criteria to the patient’s presentation and listing all current diagnoses with their ICD-10-CM codes.

Structure your Assessment section as follows:

State the primary psychiatric diagnosis with DSM-5-TR specifiers (e.g., Schizophrenia, Multiple Episodes, Currently in Acute Episode, F20.9)
List all secondary psychiatric diagnoses (e.g., comorbid Major Depressive Disorder, Tobacco Use Disorder)
List relevant medical diagnoses that impact psychiatric care
Provide a brief narrative explaining WHY the diagnosis fits using Criterion A through F
Acknowledge differential diagnoses you considered and why you ruled them out

Common Grading Error: Students list a diagnosis without explaining their reasoning. Write 2-3 sentences linking specific DSM-5-TR criteria directly to the patient’s documented symptoms. This is what separates a passing note from an excellent one.

P — Plan: Evidence-Based Treatment

The Plan section must detail a comprehensive, evidence-based treatment strategy addressing pharmacological management, psychotherapy, patient education, follow-up, and any safety planning.

For schizophrenia, your Plan should cover:

Pharmacology: Antipsychotic medication (name, dose, route, frequency), rationale for selection (e.g., clozapine for treatment-resistant schizophrenia), monitoring parameters
Non-pharmacological: CBT for psychosis (CBTp), family psychoeducation, supported employment, social skills training
Safety planning: Suicidal/homicidal ideation addressed, crisis resources provided, involuntary hold criteria if applicable
Patient education: Medication adherence importance, side effect awareness, early warning signs of relapse
Referrals/Coordination: Case management, assertive community treatment (ACT), peer support services
Follow-up: Specific timeframe with stated rationale (e.g., 2 weeks given recent medication change)
Legal/Ethical considerations: HIPAA, duty to warn, capacity assessment if needed

Full Schizophrenia SOAP Note Example (NRNP 6675 Week 5 Format)

The following is a complete, annotated model SOAP note for a patient with schizophrenia spectrum disorder, written to reflect the clinical standards expected in Walden University’s NRNP 6675 course.

SOAP NOTE — PSYCHIATRIC EVALUATION

Patient: S.T. | Age: 53 | Sex: Female | Visit Type: Follow-Up | Date: June 10, 2026

SUBJECTIVE

CC: “The voices have been worse this week. They keep telling me people are out to get me.”

HPI: S.T. is a 53-year-old female with a 20-year history of schizophrenia presenting for routine medication management follow-up. She reports a recent worsening of auditory hallucinations (2-3 commanding voices) and paranoid ideation over the past two weeks, coinciding with a reported period of medication non-adherence. She attributes the non-adherence to feeling “like the medications make me feel like a zombie.” She denies visual hallucinations at this time. No suicidal ideation, self-harm, or homicidal ideation reported. She lives alone in supervised housing and attends partial hospitalization three times weekly.

Medications: Risperidone 4 mg PO daily (reports missing 3 doses last week), Benztropine 1 mg PO daily (for EPS), Vitamin D3 2000 IU daily.

Psychiatric History: Multiple hospitalizations (last: 2023). Previous medication trials include haloperidol (discontinued due to EPS), olanzapine (discontinued due to metabolic side effects).

Substance Use: Tobacco 1 PPD (20-year history). Denies current alcohol or illicit drug use. Urine drug screen negative at last visit.

OBJECTIVE

Vitals: BP 118/76 | HR 78 | RR 16 | Temp 98.4F | Wt 167 lbs | BMI 27.1

Mental Status Examination:

Appearance: Casually dressed, adequate hygiene, appears stated age, mild psychomotor agitation noted

Behavior/Attitude: Cooperative but guarded; intermittent eye contact

Speech: Normal rate and volume; slightly tangential at times

Mood: “Anxious” (patient-reported)

Affect: Restricted; congruent with reported mood

Thought Process: Mild circumstantiality; no loose associations or flight of ideas

Thought Content: Active paranoid ideation (neighbors surveilling her); no suicidal or homicidal ideation; no obsessions or compulsions

Perceptions: Reports active AVH (3 distinct voices); states voices are commanding at times but she is resistant to acting on them

Cognition: Oriented x4; intact recent and remote memory; attention mildly impaired

Insight: Partial — acknowledges having an illness but minimizes severity

Judgment: Mildly impaired — stated she would “handle it herself” if voices worsened

ASSESSMENT

1. Schizophrenia, Multiple Episodes, Currently in Acute Episode (DSM-5-TR 295.90 / ICD-10 F20.9)

S.T. meets DSM-5-TR Criterion A through F for schizophrenia. She presents with active auditory hallucinations (Criterion A1) and persecutory delusions (Criterion A1), sustained over a period greater than six months (Criterion C), with significant functional impairment (Criterion B). Substance-induced psychosis has been excluded via negative UDS (Criterion E). Schizoaffective disorder and mood disorder with psychotic features have been considered and ruled out based on longitudinal history (Criterion D).

2. Nicotine Use Disorder, Moderate (DSM-5-TR 305.1 / ICD-10 F17.210)

Differential Diagnoses Ruled Out: Brief psychotic disorder (duration >1 month excludes), substance-induced psychosis (UDS negative), bipolar disorder with psychotic features (no manic or depressive episodes meeting full criteria documented in longitudinal history).

PLAN

Pharmacological:

1. Continue Risperidone 4 mg PO daily. Given the current exacerbation attributable to non-adherence rather than treatment failure, a dose increase is not indicated at this time. Patient counseled on the relationship between adherence and symptom control. Discussed transitioning to Risperdal Consta LAI 25 mg IM every 2 weeks to improve adherence; patient declined at this visit but willing to reconsider at next appointment.

2. Continue Benztropine 1 mg PO daily for EPS prophylaxis.

3. Labs ordered: Fasting metabolic panel, CBC, lipid panel, prolactin level — monitoring for antipsychotic-related metabolic effects per APA monitoring guidelines.

Non-Pharmacological:

4. Referral to CBT for psychosis (CBTp) provided. Coordinated with partial hospitalization program (PHP) case manager.

Safety:

5. Safety plan reviewed and updated. Patient contracted for safety. Crisis line provided: 988 Suicide and Crisis Lifeline. No evidence of imminent danger at this time. Criteria for emergency evaluation discussed with patient.

Patient Education:

6. Educated patient on importance of medication adherence and early warning signs of relapse. Provided written materials on schizophrenia spectrum disorders.

Legal/Ethical:

7. HIPAA privacy rights reviewed. Capacity to consent to treatment assessed and intact. No Tarasoff duty-to-warn obligations identified at this visit.

Follow-Up: 2 weeks, or sooner if symptoms worsen. Patient instructed to contact clinic or go to nearest ED if hearing voices commanding self-harm or harm to others.

NRNP 6675 Week 5 Assignment: What Your Rubric Actually Requires

Walden University’s NRNP 6675 Week 5 SOAP note assignment is specifically designed to assess your ability to evaluate and manage patients with schizophrenia spectrum and other psychotic disorders, including medication-induced movement disorders.

Based on Walden’s Focused SOAP Note rubric, your submission should demonstrate:

Accurate DSM-5-TR diagnosis with full criteria justification — not just a diagnosis code
A complete, clinically rigorous Mental Status Exam across all domains
Evidence-based pharmacological treatment with explicit rationale tied to peer-reviewed literature
Documentation of legal and ethical considerations relevant to the case
APA 7 in-text citations and a properly formatted reference list at the end
Assessment of medication-induced movement disorders (AIMS exam data if applicable)
Safety assessment with a documented plan

Important Note for Walden Students: Your SOAP note should reference peer-reviewed sources published within the last five years. The Stahl’s Essential Psychopharmacology textbook, APA Practice Guidelines for Schizophrenia, and SAMHSA resources are all widely accepted references for this assignment.

Common Mistakes Students Make on Schizophrenia SOAP Notes

The most common error in schizophrenia SOAP notes is a superficial Assessment section that lists a diagnosis without demonstrating diagnostic reasoning.

Avoid these critical mistakes:

Writing a vague Assessment — ‘Patient has schizophrenia’ earns minimal credit. Tie each symptom to a specific DSM-5-TR criterion.
Omitting the MSE — This is non-negotiable for psychiatric SOAP notes. Every domain must be documented.
Missing differential diagnoses — Even if schizophrenia is obvious, you must show what you ruled out and why.
Vague Plan without rationale — Don’t just write ‘continue risperidone.’ Explain why the dose is appropriate, what monitoring is needed, and what the next clinical decision point is.
No APA citations in the Plan — Your treatment recommendations must be supported by peer-reviewed evidence.
Ignoring movement disorders — NRNP 6675 Week 5 specifically includes medication-induced movement disorders. Assess for EPS, tardive dyskinesia, and akathisia.
Skipping legal/ethical section — Capacity, informed consent, and duty-to-warn documentation are required.

Antipsychotic Medications Commonly Referenced in Schizophrenia SOAP Notes

Selecting and documenting the correct antipsychotic is central to your Plan section. Here is a concise reference for the medications most frequently encountered in schizophrenia management:

Medication	Class	Typical Dose	Key Monitoring
Risperidone	2nd Gen (SGA)	2-8 mg/day	Prolactin, EPS, metabolic panel
Olanzapine	2nd Gen (SGA)	10-20 mg/day	Weight, glucose, lipids
Quetiapine	2nd Gen (SGA)	150-750 mg/day	QTc, sedation, metabolic
Aripiprazole	3rd Gen (DPA)	10-30 mg/day	Akathisia, weight
Clozapine	Atypical SGA	300-900 mg/day	ANC (REMS), metabolic, seizure
Haloperidol	1st Gen (FGA)	2-20 mg/day	EPS, tardive dyskinesia, QTc
Paliperidone	2nd Gen (SGA)	3-12 mg/day	Prolactin, QTc, renal function

Reference: Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.

How to Write Your SOAP Note vs. Getting Expert Help

Writing a high-quality schizophrenia SOAP note requires clinical knowledge, academic writing skill, and deep familiarity with your program’s rubric. For working nursing students balancing shifts, family, and coursework, this combination is not always available on a Tuesday night before a midnight deadline.

If you are confident in your clinical reasoning but struggling with APA 7 formatting, rubric alignment, or simply running out of time, there is a practical alternative. Gradevia’s nursing writers hold graduate credentials from programs like Walden University and specialize in PMHNP assignments including NRNP 6675.

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Frequently Asked Questions

What should a schizophrenia SOAP note include?

A schizophrenia SOAP note must include a subjective account of the patient’s psychotic symptoms, an objective Mental Status Exam and vital signs, an Assessment with DSM-5-TR diagnosis and differential reasoning, and a comprehensive Plan covering medications, psychotherapy, safety planning, and follow-up. For academic submissions, APA 7 citations and legal/ethical documentation are also required.

What is the DSM-5-TR code for schizophrenia?

Schizophrenia is coded as 295.90 in DSM-5-TR, with the corresponding ICD-10-CM code F20.9. Specifiers include: First Episode Currently in Acute Episode, First Episode Currently in Partial Remission, Multiple Episodes Currently in Acute Episode, and others. Always document the appropriate specifier in your Assessment section.

How do you write a mental status exam for schizophrenia?

A mental status exam for schizophrenia documents all 10 domains: appearance, behavior/attitude, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. In schizophrenia, clinicians should pay particular attention to documenting the type and content of hallucinations, the nature of delusional thinking, and whether affect is flat, blunted, or incongruent.

What is the best antipsychotic for schizophrenia in a SOAP note plan?

There is no single ‘best’ antipsychotic — the choice must be individualized and justified in your Plan. Second-generation antipsychotics (SGAs) such as risperidone, aripiprazole, and quetiapine are first-line. Clozapine is indicated for treatment-resistant schizophrenia. Your SOAP note must document why the chosen medication is appropriate for this specific patient, including prior medication history and side effect profile.

How long should a PMHNP SOAP note be?

A complete PMHNP SOAP note for a schizophrenia case typically runs 3-5 pages when written to graduate program standards. The Assessment and Plan sections are the most substantive. For Walden NRNP 6675 specifically, length is less important than depth — graders look for clinical reasoning quality, DSM-5-TR criterion documentation, and evidence-based treatment justification, not word count.

What is the difference between a focused and comprehensive psychiatric SOAP note?

A focused SOAP note targets a specific presenting problem — for example, a follow-up visit managing an acute psychosis exacerbation. A comprehensive SOAP note covers the patient’s entire psychiatric and medical history, all active diagnoses, and a full multi-system review. Walden’s NRNP 6675 Week 5 assignment requires a Focused SOAP Note, but the level of clinical depth expected is still substantial.

About the Author

Jane Halland, MSN

Senior Academic Writer | Nursing & Healthcare Graduate Programs

Jane Halland holds a Master of Science in Nursing from Walden University and has over a decade of experience in academic writing for nursing and healthcare graduate programs. She provides guidance in PMHNP clinical documentation, including psychiatric SOAP notes, case studies, and evidence-based practice projects for programs at Walden University, Grand Canyon University, Liberty University, and WGU.

As one of the writers of Gradevia.com, Jane helps working nursing students navigate the demands of graduate-level coursework with expert writing support, rubric-aligned deliverables, and a pass-or-full-refund guarantee.

References

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Article Update Log

Date	Update Summary
June 10, 2026	Original publication: comprehensive guide covering SOAP note structure for schizophrenia, full annotated NRNP 6675 Week 5 example, DSM-5-TR criteria, antipsychotic reference table, and FAQ.