I write my notes backward.
Not in the traditional SOAP format (Subjective, Objective, Assessment, Plan), but essentially in reverse:
Assessment & Plan → Data (Subjective + Objective)
So instead of SOAP, it’s more like AP–SO.
This format isn’t unheard of in medicine. It’s fairly common in internal medicine. But in psychiatry, it’s unusual enough that when colleagues cover for me, they sometimes copy my note forward and rearrange it back into standard SOAP. So clearly this is either misunderstood or mildly offensive to some people.
Let me explain why I do it this way.
At the very top of my note, I put a brief reason for admission:
John Doe is a 56-year-old male with a history of schizophrenia and hypertension admitted for acute exacerbation of psychosis in the setting of medication non-adherence.
1. Running Hospital Course
Next, I maintain a running hospital course, updated daily.
I’ll structure it by hospital day:
* Hospital Day 1: Admitted for psychosis. Started risperidone 1 mg BID and amlodipine 5 mg daily.
* Hospital Day 2: Continued disorganization and auditory hallucinations. Increased risperidone to 1 mg AM / 2 mg PM.
Just one or two sentences per day.
Why? Because at discharge, I can copy this running course directly into the discharge summary. In Epic, there’s a built-in AI summarization tool that converts it into paragraph form. So I’m essentially writing my discharge summary in real time, a little bit each day.
It saves me a ton of cognitive load at the end.
Problem-Based Assessment and Plan
After the hospital course, I move directly into a problem-based plan.
Each problem gets its own header:
# Auditory hallucinations / disorganized thought
Under that:
* Working diagnosis: Schizophrenia
* If needed: Differential diagnosis
* Workup (labs, studies)
* Treatment plan
If it’s straightforward, e.g. known schizophrenia with medication non-adherence, I keep it simple.
If it’s undifferentiated, like:
# Erratic behavior
Then I’ll structure it more explicitly:
* Working diagnosis: Psychosis unspecified
* Differential: Substance-induced psychosis, schizophrenia, schizoaffective disorder, acute mania, encephalopathy
* Workup: labs, UDS, imaging if indicated
* Treatment plan
If it’s complex, I’ll add some prose explaining my reasoning, for clarity and for liability purposes. But I generally don’t write long narrative assessment paragraphs the way many psychiatry notes do.
The problem list always includes:
* The primary psychiatric problem(s)
* Medical comorbidities
* Risk assessment and mitigation (suicide precautions, fall precautions, etc.)
* Discharge planning
And yes, I start thinking about discharge on day one.
Are they going back to a shelter? A group home? Do we need a substance use referral? Guardianship? Long-acting injectable planning?
That’s all part of the plan.
Then Comes the Data
Only after I’ve written the assessment and plan do I move to the data section.
That includes:
* Subjective
* Objective
* Labs
* Vitals
* Mental status exam
* Physical exam
To me, the subjective is just data. What the patient tells me is important, but it’s still data that feeds into the larger synthesis.
I don’t start with a long narrative of what the patient said and then slowly build toward a conclusion. I already know what I’m treating and what decisions I’m making. The data supports that.
Why This Works Better for Me
1. It Reflects How I Actually Think
When I see a patient, I’m already forming an assessment and plan in real time. The note should reflect that.
Starting with the plan forces clarity:
* What are the actual problems?
* What am I doing about them?
* What’s the working diagnosis?
* What needs workup?
Once that’s clear, the subjective and objective sections become focused. I’m not transcribing everything the patient says. I’m documenting what’s relevant to the clinical questions I’m answering.
It’s a filter.
2. It Improves Readability
Let’s be honest: most people reading notes want to know the bottom line.
If you’re covering me tomorrow, you don’t want to scroll through three paragraphs of subjective narrative to find the risperidone dose change.
You want the assessment and plan.
So I put it at the top.
3. It Keeps Me Focused
When I’m writing multiple notes in a row, it gets tedious and I lose my attention especially when starting with the subjective.
If I start with assessment and plan, I’m forced to:
* Confirm diagnoses
* Adjust meds
* Update orders
* Address risk issues
* Think about discharge
That’s the high-value work.
Once that’s done, filling in the data is relatively mechanical.
It also helps me avoid missing order changes. Writing the plan first sometimes reminds me of something I forgot to put in.
A Simple Template
Here’s a simplified version of what this looks like in practice.
Reason for Admission
56-year-old male with schizophrenia and hypertension brought in by police for erratic behavior in public in the setting of medication non-adherence.
Running Hospital Course
* HD1: Admitted for erratic behavior, appears to be psychosis whether primary or secondary. Started risperidone 1 mg BID. Continued amlodipine 5 mg home med for HTN.
* HD2: Persistent AH and disorganization. Increased risperidone to 1 mg AM / 2 mg PM.
Assessment & Plan
# Erratic behavior
* Working diagnosis: Psychosis, unspecified
* Differential: Substance-induced psychosis (UDS+ for cocaine), schizophrenia, schizoaffective disorder, mania, delirium, medical cause
* Workup: CBC, CMP, TSH, UDS
* Treatment:
* Risperidone 1 mg AM / 2 mg PM
* Monitor EPS, prolactin
* Consider LAI prior to discharge
# Hypertension
* Continue amlodipine 5 mg daily
# Risk Assessment / Mitigation
* Suicide precautions: Q15 checks
# Discharge Planning
* Anticipated discharge to group home
* Coordinate outpatient psychiatry follow-up
* Evaluate for LAI prior to discharge
Data (abbreviated)
Subjective
Patient reports ongoing voices commenting on behavior. Denies SI/HI. Reports poor sleep.
Objective
* Vitals stable
* Labs pending
* MSE: Disorganized thought process, AH present, insight limited
* PE: No rigidity in UE
