As a psychologist or psychotherapist, writing SOAP notes is an essential part of the job. SOAP notes are a type of progress note used to document a patient's treatment plan and progress. They include subjective, objective, assessment, and plan sections, hence the acronym SOAP. In this blog post, we will provide some examples of SOAP notes for mental health professionals.
Example 1: Anxiety Disorder
Subjective: The patient reports feeling extremely anxious most days. They describe feelings of worry, restlessness, and difficulty sleeping.
Objective: The patient appears anxious during the session, with tense body language and frequent fidgeting. The patient's heart rate and blood pressure are elevated.
Assessment: The patient meets the criteria for Generalized Anxiety Disorder. Their symptoms have persisted for more than six months and are causing significant distress and impairment in their daily life.
Plan: The patient will be referred to a psychiatrist for medication management and will begin weekly therapy sessions to learn coping skills for managing anxiety.
Example 2: Major Depressive Disorder
Subjective: The patient reports feeling sad and hopeless most days. They have lost interest in their hobbies and struggle with feelings of worthlessness and guilt.
Objective: The patient appears depressed during the session, with slumped posture and minimal eye contact. The patient has experienced significant weight loss and reports difficulty sleeping.
Assessment: The patient meets the criteria for Major Depressive Disorder. Their symptoms have persisted for more than two weeks and are causing significant distress and impairment in their daily life.
Plan: The patient will be referred to a psychiatrist for medication management and will begin weekly therapy sessions to learn coping skills for managing depression.
Example 3: Post-Traumatic Stress Disorder (PTSD)
Subjective: The patient reports experiencing flashbacks and nightmares related to a traumatic event they experienced several years ago. They describe feelings of fear and avoidance.
Objective: The patient appears agitated during the session, with rapid breathing and frequent pauses in speech. The patient has experienced significant sleep disturbances and hypervigilance.
Assessment: The patient meets the criteria for Post-Traumatic Stress Disorder. Their symptoms have persisted for more than a month and are causing significant distress and impairment in their daily life.
Plan: The patient will be referred to a psychiatrist for medication management and will begin weekly therapy sessions to learn coping skills for managing PTSD.
It is important to note that SOAP notes should be tailored to the individual patient and their unique symptoms and treatment plan. These examples provide a basic framework for how to structure SOAP notes for mental health professionals.
In conclusion, SOAP notes are an important tool for psychologists and psychotherapists to document their patients' progress and treatment plans. They provide a structured way to communicate with other healthcare professionals and ensure that patients receive appropriate care. By using SOAP notes and tailoring them to each patient's needs, mental health professionals can provide effective treatment and improve their patients' overall well-being.
Book a demo
Save time by letting uMore Practice do all the admin work for you.
