10 Mental Health SOAP Note Examples to Inspire Accurate Documentation
As healthcare professionals, documenting our patients’ mental health conditions is crucial to providing quality care and ensuring proper treatment plans. The SOAP note (Subjective, Objective, Assessment, and Plan) is a widespread method used to document patient encounters. However, creating accurate and comprehensive SOAP notes can be a daunting task, particularly in the mental health field.
To inspire accurate documentation, let’s take a look at ten examples of SOAP notes for common mental health conditions.
1. Major Depressive Disorder (MDD)
Subjective: The patient reports feeling sad, losing interest in activities, and experiencing fatigue and difficulty concentrating.
Objective: Vital signs are within normal limits. The patient displays psychomotor agitation and appears tearful.
Assessment: The patient meets criteria for MDD and has a low suicide risk.
Plan: Started on fluoxetine 20mg daily and referred to a therapist for cognitive-behavioral therapy (CBT).
2. Generalized Anxiety Disorder (GAD)
Subjective: The patient reports excessive worry, sleep disturbance, and irritability.
Objective: Vital signs are within normal limits. The patient presents with muscle tension and restlessness.
Assessment: The patient meets criteria for GAD and has a moderate suicide risk.
Plan: Started on escitalopram 10mg daily and referred to a psychiatrist for evaluation of benzodiazepine use.
3. Bipolar Disorder (BD)
Subjective: The patient reports episodes of elevated and irritable mood, racing thoughts, and decreased need for sleep.
Objective: Vital signs are within normal limits. The patient displays increased psychomotor activity and speech.
Assessment: The patient meets criteria for BD and has a low suicide risk.
Plan: Started on lithium 600mg daily and referred to a therapist for psychoeducation.
4. Attention-Deficit/Hyperactivity Disorder (ADHD)
Subjective: The patient reports difficulty focusing, forgetfulness, and impulsivity.
Objective: Vital signs are within normal limits. The patient presents with fidgeting and interrupting.
Assessment: The patient meets criteria for ADHD and has no suicide risk.
Plan: Started on methylphenidate 10mg twice daily and referred to a therapist for behavioral interventions.
5. Posttraumatic Stress Disorder (PTSD)
Subjective: The patient reports nightmares, flashbacks, and avoidance of triggers.
Objective: Vital signs are within normal limits. The patient displays hyperarousal and startle response.
Assessment: The patient meets criteria for PTSD and has a low suicide risk.
Plan: Started on paroxetine 20mg daily and referred to a therapist for trauma-focused therapy.
6. Obsessive-Compulsive Disorder (OCD)
Subjective: The patient reports intrusive thoughts and compulsions.
Objective: Vital signs are within normal limits. The patient displays repetitive behaviors and mental rituals.
Assessment: The patient meets criteria for OCD and has no suicide risk.
Plan: Started on fluvoxamine 50mg daily and referred to a therapist for exposure and response prevention (ERP) therapy.
7. Schizophrenia
Subjective: The patient reports hearing voices and having delusions.
Objective: Vital signs are within normal limits. The patient presents with disorganized speech and behavior.
Assessment: The patient meets criteria for schizophrenia and has a high suicide risk.
Plan: Started on risperidone 4mg daily and referred to a psychiatrist for ongoing management.
8. Borderline Personality Disorder (BPD)
Subjective: The patient reports unstable and intense relationships, mood swings, and feelings of emptiness.
Objective: Vital signs are within normal limits. The patient presents with self-injurious behaviors and suicidal ideation.
Assessment: The patient meets criteria for BPD and has a high suicide risk.
Plan: Started on dialectical behavior therapy (DBT) and referred to a psychiatrist for pharmacological management.
9. Alcohol Use Disorder (AUD)
Subjective: The patient reports drinking more than intended, experiencing cravings, and having difficulty stopping.
Objective: Vital signs are within normal limits. The patient displays tremors and hyperalertness.
Assessment: The patient meets criteria for AUD and has a moderate suicide risk.
Plan: Started on acamprosate 666mg three times daily and referred to a therapist for relapse prevention.
10. Substance Use Disorder (SUD)
Subjective: The patient reports using multiple substances, losing control of their use, and needing larger amounts to achieve the same effect.
Objective: Vital signs are within normal limits. The patient displays withdrawal symptoms and track marks.
Assessment: The patient meets criteria for SUD and has a high suicide risk.
Plan: Started on buprenorphine/naloxone 16mg/4mg daily and referred to a therapist for harm reduction.
In conclusion, documenting mental health conditions through accurate and well-structured SOAP notes is crucial to the patients’ well-being. The above examples illustrate the use of the SOAP note in common mental health conditions, highlighting the importance of proper documentation to provide effective care. As healthcare professionals, we must strive to deliver quality care by documenting our patients’ medical history, symptoms, interventions, and response.
