Can you write a SOAP note for a face‑to‑face reassessment of Alpha‑Stim (transcranial magnetic stimulation) therapy in a 64‑year‑old female who reports it helps a lot, with PHQ‑9 (Patient Health Questionnaire‑9) score 4 and GAD‑7 (Generalized Anxiety Disorder‑7) score 8, no new health concerns, a primary care provider, and taking amlodipine, metformin, semaglutide (Ozempic) and a respiratory inhaler?

SOAP Note: Alpha-Stim Reassessment

SUBJECTIVE: 64-year-old female presents for face-to-face Alpha-Stim reassessment. Patient reports Alpha-Stim therapy "helps her a lot" with subjective improvement in symptoms. Denies new health concerns. Reports established care with primary care provider.

Current Medications:

• Amlodipine (hypertension)
• Metformin (diabetes)
• Semaglutide/Ozempic (diabetes/weight management)
• Inhaler (respiratory condition, specific agent not documented)

OBJECTIVE:

Mental Health Screening:

• PHQ-9 score: 4 (minimal depression symptoms; scores 1-7 indicate none/mild symptomatology) 1
• GAD-7 score: 8 (mild anxiety symptoms; scores 5-9 suggest mild anxiety) 2, 3

Vital Signs: Not documented in visit note

ASSESSMENT:

1. Minimal depressive symptoms (PHQ-9 = 4)

• Patient demonstrates excellent response to current Alpha-Stim therapy with PHQ-9 in the minimal range 1
• No suicidal ideation per PHQ-9 item 9 screening 1, 4
• Functional status appears preserved with no reported concerns

2. Mild anxiety symptoms (GAD-7 = 8)

• GAD-7 score of 8 falls just above the traditional cutoff of ≥8 for moderate symptomatology, though some guidelines use ≥9 as the threshold for clinical concern 1, 3
• The GAD-7 demonstrates 73% sensitivity and 70% specificity at a cutoff of ≥9 for recognizing individuals at risk for anxiety disorders 3
• Patient's subjective report of Alpha-Stim benefit suggests adequate symptom management

3. Chronic medical conditions - stable

• Type 2 diabetes mellitus on metformin and semaglutide
• Hypertension on amlodipine
• Respiratory condition requiring inhaler therapy
• All managed by established PCP

PLAN:

1. Continue Alpha-Stim therapy

• Patient demonstrates clear clinical benefit with PHQ-9 and GAD-7 scores in the minimal-to-mild range, supporting continuation of current neuromodulation therapy 5, 6
• Transcranial magnetic stimulation modalities have demonstrated 58-83% response rates and 28-62% remission rates in major depressive disorder across clinical practice settings 6
• The 2022 VA/DoD guidelines upgraded repetitive transcranial magnetic stimulation (rTMS) to a higher-level recommendation for depression management 5

2. Monitoring and reassessment

• Readminister PHQ-9 and GAD-7 at next visit (recommended monthly intervals until symptoms remain stable) 1
• Monitor for any increase in PHQ-9 score to ≥8 or GAD-7 score to ≥9, which would warrant consideration of additional interventions 1, 3
• Specifically assess PHQ-9 item 9 (suicidal ideation) at each visit, as any positive response requires immediate mental health referral 1, 4

3. Patient education

• Provided education about maintaining current therapeutic gains and recognizing early warning signs of symptom worsening 1
• Discussed importance of continued adherence to Alpha-Stim protocol
• Reviewed when to seek urgent evaluation (suicidal thoughts, severe anxiety, functional impairment) 1, 4

4. Coordination of care

• Patient maintains established relationship with PCP for management of diabetes, hypertension, and respiratory condition
• No medication adjustments indicated at this visit
• Will communicate reassessment findings to PCP as appropriate

5. Follow-up

• Schedule next Alpha-Stim reassessment in 4 weeks
• Patient instructed to contact clinic sooner if symptoms worsen or new concerns arise
• Continue current Alpha-Stim treatment frequency and parameters