Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic insomnia, evaluation of persistent sleep problems, or medication management.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of sleep problems:
Duration of insomnia (more than 3 months, at least 3 nights per week)
Difficulty falling asleep (sleep latency)
Difficulty maintaining sleep (frequent awakenings, early morning awakening)
Non-restorative sleep (feeling tired even after sleep)
Daytime symptoms (fatigue, irritability, difficulty concentrating)
Sleep hygiene practices (bedtime routine, screen time before bed)
Stress levels and impact on sleep
Naps (frequency and duration)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying medical or psychiatric conditions that might contribute to insomnia (e.g., anxiety, depression, chronic pain, sleep apnea)
Medications that can disrupt sleep (e.g., stimulants, some antidepressants)
Past sleep studies (if applicable)
Social History:
Inquire about work schedule (shift work, irregular sleep patterns).
Ask about caffeine and alcohol intake, which can affect sleep.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Mental Status Exam:
Briefly assess mood, anxiety, and cognitive function.
Assessment (A):
Type of Insomnia:
Based on the history, categorize the insomnia as primary (no identifiable cause) or secondary (caused by another medical or psychiatric condition).
Sleep Hygiene:
Evaluate the patient’s sleep hygiene practices and identify potential areas for improvement.
Impact of Insomnia:
Assess the impact of insomnia on the patient’s daytime functioning and overall well-being.
Differential Diagnosis:
Consider other sleep disorders that may mimic insomnia (e.g., sleep apnea, restless legs syndrome) based on history and may require further evaluation.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the type and severity of insomnia. Options may include:
Non-pharmacological interventions:
Cognitive behavioral therapy for insomnia (CBT-I): first-line treatment, focuses on improving sleep habits and relaxation techniques.
Sleep hygiene education: improving bedtime routine, creating a sleep-conducive environment, avoiding stimulants before bed.
Relaxation techniques (e.g., progressive muscle relaxation, mindfulness meditation).
Medications: Consider sleep medications for short-term relief, especially if non-pharmacological interventions are not effective alone.
Treating underlying conditions: If insomnia is secondary to another medical or psychiatric condition, address the underlying issue.
Follow-up:
Schedule follow-up visits to monitor sleep improvement, assess response to treatment, and adjust the plan as needed.
Define the frequency of follow-up based on severity of insomnia and response to treatment.
Patient Education:
Educate the patient about chronic insomnia, its causes and consequences.
Explain the importance of good sleep hygiene practices and provide resources for improving sleep habits.
Discuss treatment options, including potential benefits and risks of medications (if applicable).
Offer resources for support groups or educational materials on managing chronic insomnia.