5 Examples of SOAP Notes in Mental Health
SOAP (Subjective, Objective, Assessment, Plan) notes are a widely used tool in mental healthcare for tracking client progress and providing a structured approach to treatment. They allow mental health professionals to develop and modify treatment plans, track client outcomes, and ensure continuity of care. Here are five examples of SOAP notes in mental health:
1. Depression
Subjective: The client reported feeling sad, hopeless, and unmotivated over the past week. They noted difficulty sleeping, loss of appetite, and decreased interest in activities they once enjoyed.
Objective: Client appeared tearful and withdrawn during the session. The clinician observed slowed speech and reduced energy levels. The client’s rating on the Beck Depression Inventory was 27, indicating severe depression.
Assessment: The client met the criteria for major depressive disorder. They have experienced a significant impact on their ability to function both personally and professionally.
Plan: The clinician will introduce cognitive-behavioral techniques to address negative thoughts, identify and modify unhelpful thinking patterns, and increase positive activities. They will also explore medication options with the client.
2. Anxiety
Subjective: The client reported feeling nervous, worried, and on edge for most of the day. They noted difficulty concentrating, physical symptoms such as sweating, and avoidance of situations that trigger anxiety.
Objective: The clinician observed fidgeting and frequent checking of the time during the session. The client’s heart rate was elevated, and their breathing was shallow. They scored a 25 on the Beck Anxiety Inventory, indicating moderate to severe anxiety.
Assessment: The client met the criteria for generalized anxiety disorder. They have experienced a significant impact on their ability to function both personally and professionally.
Plan: The clinician will introduce relaxation techniques, such as deep breathing and progressive muscle relaxation, to reduce physical symptoms. They will also explore cognitive-behavioral techniques to address negative thoughts and increase the client’s ability to tolerate anxious situations.
3. Substance Use
Subjective: The client reported binge drinking on weekends and using cocaine occasionally to relax and socialize. They noted feeling guilty about their substance use and worried about its impact on their life.
Objective: The clinician observed the client appeared anxious and restless during the session. They noted dilated pupils and increased perspiration. The client’s score on the Addiction Severity Index was at a high level, indicating a significant impact on multiple areas of their life.
Assessment: The client met the criteria for substance use disorder. They have experienced a significant impact on their ability to function both personally and professionally.
Plan: The clinician will introduce motivational interviewing techniques to explore the client’s ambivalence towards substance use. They will also discuss harm reduction strategies and refer the client to a support group.
4. Eating Disorders
Subjective: The client reported restricting their food intake, feeling preoccupied with thoughts of food, and being dissatisfied with their body shape and weight. They noted feelings of guilt and shame around their eating habits.
Objective: The clinician observed the client appeared emaciated, with thinning hair and dry skin. They noted the client had missed three menstrual cycles. The client’s score on the Eating Disorder Inventory was at a severe level, indicating a significant impact on their quality of life.
Assessment: The client met the criteria for anorexia nervosa. They have experienced a significant impact on their ability to function both personally and professionally.
Plan: The clinician will introduce cognitive-behavioral techniques to address negative thoughts and increase the client’s ability to tolerate food-related anxiety. They will also refer the client to a specialized eating disorder treatment program and monitor medical status closely.
5. Trauma
Subjective: The client reported experiencing a traumatic event, which has caused flashbacks, nightmares, and feelings of detachment. They noted a sense of shame and guilt around the event.
Objective: The clinician observed the client appeared anxious and distressed during the session. They noted hyperarousal symptoms such as increased alertness and startle response. The client’s score on the Trauma Symptom Inventory was at a high level, indicating a significant impact on their quality of life.
Assessment: The client met the criteria for post-traumatic stress disorder. They have experienced a significant impact on their ability to function both personally and professionally.
Plan: The clinician will introduce trauma-focused cognitive-behavioral therapy to address negative thoughts and maladaptive coping mechanisms. They will also refer the client to a support group and monitor symptoms closely.
In conclusion, SOAP notes provide mental health professionals with a structured approach to treatment and tracking client progress. They allow for effective communication and ensure continuity of care. In each of the five examples discussed, clients have experienced a significant impact on their lives. The presented plans of treatment adhere to evidence-based practices to address each issue effectively. Mental health professionals can utilize SOAP notes to effectively manage clients’ needs and provide the best care possible.
