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Psychiatric SOAP Note: Template, Examples & How to Write One

Q: Do psychiatrists use SOAP notes?

Yes. SOAP is one of the most common formats in psychiatry because it organizes a visit into Subjective, Objective, Assessment, and Plan — a structure that fits psychiatric care well, with the mental status exam documented inside the Objective section. Some clinicians also use DAP or BIRP formats, but SOAP remains a standard for both intake and medication-management visits.

Q: What is the mental status exam in a psychiatric SOAP note?

The mental status exam (MSE) is the structured set of observations that lives in the Objective section: appearance, behavior, speech, mood and affect, thought process and content, perception (hallucinations), cognition and orientation, and insight and judgment. It is the psychiatric equivalent of a physical exam and is what makes a psych SOAP note different from one in other specialties.

Q: What is a psychiatric nursing notes example in SOAP format?

Inpatient psychiatric nurses often use SOAPIE — SOAP plus Intervention and Evaluation. For example: S: patient reports sleeping well and feeling ready for group; O: awake, dressed, ate breakfast, vitals stable; A: mood improved from yesterday; P: encourage group attendance; I: accompanied patient to group; E: participated fully and shared a coping skill. See our full guide to psychiatric nursing notes for more formats and examples.

Q: Can an AI scribe write psychiatric SOAP notes?

Yes. An ambient AI scribe like Augustun listens during the encounter and drafts a structured SOAP note — including a mental status exam, ICD-10 suggestions, and a plan — in seconds. It supports SOAP, SOAPIE, DAP, and BIRP formats, is HIPAA compliant, never stores recordings, and connects to 400+ EHRs via a browser extension. You always review and sign before the note is finalized.

Dr. Medeline Yost

Chief Medical Officer, Augustun

Published June 15, 2026

Updated June 15, 2026

On this page

What Is a Psychiatric SOAP Note?
Psychiatric SOAP Note vs. Psychotherapy Note
The Four Sections of a Psychiatric SOAP Note
Psychiatric SOAP Note Template
Psychiatric SOAP Note Examples
How to Write a Strong Psychiatric SOAP Note
Psychiatric Nursing Notes Example (SOAPIE)
What to Include and Exclude
Common Psychiatric SOAP Note Mistakes
Let an AI Scribe Write Your Psychiatric Notes
Conclusion
FAQ

Unlike specialties where a lab value or a scan can tell most of the story, psychiatry runs on nuance. A word choice, a shift in affect, a micro-expression — each one can change your diagnosis and your treatment plan. But when your attention is split between the patient in front of you and the chart you still have to finish, it is easy to miss the small risk markers that matter most. A well-structured psychiatric SOAP note is what keeps those details from slipping away.

The psychiatric SOAP note gives you one organized, repeatable format to capture what the patient said, what you observed, what you concluded, and what you plan to do next — without flattening the clinical detail that makes psychiatry psychiatry. Done well, it makes charting faster, supports medical necessity for billing, and protects you if a record is ever audited or subpoenaed.

This guide walks through every section of a psychiatric SOAP note, gives you a fillable template, four complete worked examples across common presentations, and a psychiatric nursing notes example for inpatient teams. If you want the broader picture of psychiatric documentation beyond SOAP, see our companion guide on how to write psychiatry notes.

What Is a Psychiatric SOAP Note?

A psychiatric SOAP note is a structured clinical note that documents a psychiatric evaluation or follow-up visit using four sections: Subjective, Objective, Assessment, and Plan. It lives in the patient's official medical record, justifies the medical necessity of your care, and communicates your clinical reasoning to everyone else on the treatment team — therapists, primary care providers, nurses, and sometimes insurers and the patient.

What sets a psych note apart from a SOAP note in other specialties is the weight it places on the patient's own words, their mental status, behavior, and risk. There is rarely a definitive test to point to, so your documentation has to carry the clinical logic itself: what is happening, why it matters, and what you are doing about it.

SOAP notes are used across outpatient clinics, inpatient units, emergency settings, and telepsychiatry. Whatever the setting, the goal is the same — a note that is clear enough for the next clinician to act on without having to call you.

Psychiatric SOAP Note vs. Psychotherapy Note

Psychiatrists and therapists often keep two kinds of records, and confusing them is a compliance risk. A psychiatric SOAP note goes into the official medical record. A psychotherapy (or process) note is the clinician's private working document and is not part of the record. Knowing the difference means you never accidentally put sensitive process material somewhere an insurer can request it.

	Psychiatric SOAP Note	Psychotherapy Note
Purpose	Communicate clinical information to the care team and justify billing	Support the clinician's own reasoning and treatment planning
Focus	Symptoms, mental status, diagnoses, medications, and the plan	Session content, impressions, and hypotheses
Part of the record?	Yes — added to the official medical record	No — kept separate from the record
Who can access it	Treating providers; can be requested by patients and insurers	Special HIPAA protection; generally needs specific authorization
Standard	Must meet documentation rules for reimbursement and medical necessity	Optional, as detailed or sparse as helps your process

The Four Sections of a Psychiatric SOAP Note

Every psychiatric SOAP note is built from the same four blocks. Here is what belongs in each, with psychiatry-specific guidance for what to capture.

S — Subjective

This is the patient's experience in their own words. Capture the chief complaint, the history of present illness, symptom onset and duration, and direct quotes that show impact. Quotes are powerful here — "I have to push myself to work extra hours every week" tells a reviewer far more than "reports work stress." Include self-management the patient has tried and how well it worked, plus relevant history (family, substance use, trauma) when it informs care.

O — Objective

This is what you observe and measure — facts, not interpretation. In psychiatry the centerpiece is the mental status exam (MSE): appearance, behavior, speech, mood and affect, thought process and content, perception (hallucinations), cognition, insight, and judgment. Add any vitals, rating-scale scores (PHQ-9, GAD-7, MDQ), and labs. Write what you see — "constricted affect, psychomotor slowing" — rather than what you assume.

A — Assessment

This is your clinical judgment. State the working diagnosis with ICD-10 codes, tie it to specific DSM-5 criteria, note differential diagnoses and what you are ruling out, and give your impression of severity and change since the last visit. This is the section that demonstrates your reasoning, so make the logic explicit rather than just listing a code.

P — Plan

This is what happens next: medication decisions with your rationale, therapy or referrals, labs ordered, the safety plan, patient education provided, and the follow-up interval. Each item should connect back to something in the Assessment so the plan reads as a direct response to the clinical picture.

Where the mental status exam lives

The MSE is not a separate section — it sits inside Objective. Many psychiatrists format it as a short labeled block so the next reader can scan appearance, mood/affect, thought process, perception, cognition, insight, and judgment at a glance.

Psychiatric SOAP Note Template

Use this as a fillable skeleton. Copy it, drop in your findings, and trim anything that does not apply to the visit. It works for both intake and follow-up med-management visits.

Psychiatric SOAP Note — Template

S (Subjective): Chief complaint in the patient's words. History of present illness: onset, duration, severity, triggers, and course. Direct quotes showing functional impact. Self-management attempted and its effect. Relevant psychiatric, family, substance, and trauma history.
O (Objective) — Mental Status Exam: Appearance and behavior. Speech (rate, volume, tone). Mood (patient's words) and affect (your observation). Thought process and thought content. Perception (hallucinations present/absent). Cognition, orientation, and concentration. Insight and judgment. Vitals and rating-scale scores (e.g., PHQ-9, GAD-7).
A (Assessment): Working diagnosis with ICD-10 code(s) and supporting DSM-5 criteria. Differential diagnoses and what is being ruled out (R/O). Severity and specifiers. Change since last visit. Explicit suicide/homicide risk formulation with risk and protective factors.
P (Plan): Medication: start/continue/adjust with rationale. Therapy and referrals. Labs and monitoring. Safety plan and crisis resources. Patient education provided. Follow-up interval and what will be re-assessed.

Psychiatric SOAP Note Examples

Templates are easier to use once you have seen them filled in. Here are four complete psychiatric SOAP note examples across common presentations. Names and details are illustrative.

Example 1 — Depression and Anxiety (Initial Visit)

Andy is a 30-year-old sales executive who feels overwhelmed at a new job. This is his first psychiatry session.

Psychiatric SOAP Note — Depression and Anxiety

S (Subjective): 30-year-old male reports "feeling overwhelmed" for the past three months. Symptoms include persistent low mood, difficulty concentrating, sleep-onset insomnia, early-morning waking, a 7 lb unintentional weight loss, and irritability. States, "I have to push myself to work extra hours every week." Tried exercise and meditation with minimal benefit. Family history of depression. Denies prior psychiatric treatment.
O (Objective): Well-groomed but appears tired. Speech normal in rate and volume. Mood "stressed and down"; affect constricted. Thought process logical and goal-directed; no delusions or obsessions. No perceptual disturbances. Alert and oriented x3 with mild concentration impairment. Insight good, judgment intact. PHQ-9 = 16; GAD-7 = 14. Vitals stable: BP 128/82, HR 88.
A (Assessment): 1) Major Depressive Disorder, moderate (F32.1) — meets DSM-5 criteria including depressed mood, anhedonia, sleep disturbance, weight loss, and diminished concentration. 2) Generalized Anxiety Disorder (F41.1). 3) R/O Adjustment Disorder with mixed anxiety and depressed mood. No history of manic episodes to suggest bipolar disorder. Suicide risk: denies ideation, plan, or intent; protective factors include strong work motivation and treatment engagement — low acute risk.
P (Plan): Start sertraline 50 mg daily x1 week, then increase to 100 mg. Lorazepam 0.5 mg PRN anxiety (max 6/month). Sleep hygiene counseling and graded exercise. Basic labs (CBC, CMP, TSH) to rule out medical contributors. Begin weekly CBT. Safety plan and crisis-line resources provided. Follow-up in 2 weeks with repeat PHQ-9 and GAD-7.

Example 2 — Bipolar Disorder (Medication Follow-Up)

Maria is a 42-year-old returning for a routine medication management visit. This shows how a follow-up SOAP note differs from an intake.

Psychiatric SOAP Note — Bipolar Follow-Up

S (Subjective): 42-year-old female with Bipolar I Disorder returns for 6-week follow-up. Reports stable mood since the last visit: "I finally feel like myself." Sleeping 7–8 hours, no racing thoughts, no overspending or impulsivity. Taking lamotrigine and quetiapine as prescribed; reports mild morning grogginess but "nothing I can't handle." Denies missed doses. No recent stressors.
O (Objective): Casually dressed, well-groomed. Speech normal rate, no pressure. Mood "good"; affect full and congruent. Thought process linear; no flight of ideas or grandiosity. No perceptual disturbances. Cognition intact. Insight and judgment good. No abnormal involuntary movements. Recent lamotrigine level therapeutic; CMP within normal limits.
A (Assessment): Bipolar I Disorder, most recent episode manic, in full remission (F31.74). Mood euthymic and stable on current regimen for 6 weeks. No evidence of mania, hypomania, or depression. No medication-limiting side effects. Suicide/homicide risk: denies ideation — low risk. Maintenance phase; goal is relapse prevention.
P (Plan): Continue lamotrigine 200 mg daily and quetiapine 50 mg qHS at current doses given good response and tolerability. Reinforced sleep-wake regularity as relapse trigger. Reviewed early warning signs of mood episodes. Continue monthly therapy. Repeat CMP and lamotrigine level in 3 months. Follow-up in 8 weeks; return sooner if mood symptoms emerge.

Example 3 — Psychosis / Schizophrenia (Inpatient)

David is a 27-year-old admitted with a first psychotic episode. Notice how the Objective section carries far more MSE detail.

Psychiatric SOAP Note — Psychosis

S (Subjective): 27-year-old male, brought in by family for 3 weeks of increasingly disorganized behavior. States, "The TV is sending me messages and people on the street know my thoughts." Reports hearing "two voices arguing about me" for the past month. Sleep markedly reduced; eating poorly. Denies substance use; toxicology pending. No prior psychiatric history per family.
O (Objective): Disheveled, malodorous, wearing layered clothing despite warm room. Guarded, intermittent eye contact, responds to internal stimuli (appears to track unseen stimuli, mutters). Speech tangential. Mood "fine"; affect flat and incongruent. Thought process disorganized with loose associations. Thought content: paranoid delusions and ideas of reference. Perception: auditory hallucinations, command type denied. Oriented x3; concentration poor. Insight absent; judgment impaired.
A (Assessment): Schizophrenia, first episode, currently in acute episode (F20.9) vs. substance-induced psychotic disorder pending toxicology and brief psychotic disorder given <1 month duration of some symptoms. Meets DSM-5 criteria with delusions, hallucinations, and disorganized thought. Risk: command hallucinations denied but limited insight and disorganization raise safety concern — moderate risk requiring inpatient monitoring.
P (Plan): Admit to inpatient unit, 15-minute safety checks. Start risperidone 1 mg BID, titrate as tolerated; discussed metabolic monitoring with patient and family. Labs: CBC, CMP, TSH, urine toxicology, prolactin baseline. Rule out organic causes. Psychoeducation for patient and family. Reassess MSE daily. Social work for housing and support coordination.

Example 4 — PTSD (Outpatient Follow-Up)

A telepsychiatry follow-up for a 35-year-old veteran with PTSD, illustrating risk documentation done well.

Psychiatric SOAP Note — PTSD

S (Subjective): 35-year-old male veteran returns for 4-week follow-up for PTSD. Reports nightmares have decreased from nightly to 2–3 times per week since starting prazosin. Still avoids crowds and "jumps at loud noises." States, "I don't want to be here some days, but I'd never act on it — my kids need me." Engaged in weekly trauma-focused therapy. Sleeping ~5 hours.
O (Objective): Appropriately dressed, mild psychomotor tension. Speech normal. Mood "up and down"; affect anxious but reactive. Thought process linear. No psychosis. Hypervigilant. Oriented x3, cognition intact. Insight good, judgment intact. PCL-5 = 42 (down from 55 four weeks ago).
A (Assessment): Post-Traumatic Stress Disorder, chronic (F43.12), with partial response to treatment — nightmares and PCL-5 improving, avoidance and hyperarousal persist. Suicide risk: endorses passive ideation ("don't want to be here some days") but denies active ideation, plan, or intent. Strong protective factors: connection to children, treatment engagement, no access to means, agreement to safety plan. Low-to-moderate risk; warrants ongoing monitoring.
P (Plan): Continue prazosin 3 mg qHS; increase sertraline from 50 mg to 100 mg daily for residual avoidance and hyperarousal. Continue weekly trauma-focused CBT. Safety plan reviewed and updated; patient contracted to call crisis line if passive ideation intensifies. Sleep hygiene reinforced. Follow-up in 3 weeks with repeat PCL-5.

How to Write a Strong Psychiatric SOAP Note

A good template is only half the job. These five habits separate a note that gets reimbursed and holds up under audit from one that triggers a denial.

1. Document medical necessity with precision

Insurers need clear evidence that your care is medically necessary, and vague notes lead to denied claims. Use patient quotes that show impact, document failed self-management, and connect symptoms to real functional losses. Example: "The patient's anxiety (persistent worry, insomnia, poor concentration) has caused two missed project deadlines and significant relationship strain. Self-directed breathing exercises gave minimal relief. Weekly CBT and medication management are medically necessary to prevent further deterioration."

2. Support the diagnosis with DSM-5 criteria

Treat your Assessment as an audit trail. Specify which criteria you met ("meets 7/9 DSM-5 criteria for MDD"), document negative findings ("no history of manic episodes to suggest bipolar disorder"), add specifiers ("MDD, moderate, with anxious distress"), and note differentials when the picture is unclear. This is your line of defense if a record is ever reviewed.

3. Quantify symptoms and progress

Use standardized rating scales consistently so improvement is visible over time. Record both the number and what it means: "PHQ-9 decreased from 21 to 16 — modest improvement but still moderately severe depression. Sleep improved most (3 to 1); concentration unchanged (3). Patient returned to part-time work, a functional gain from baseline."

4. Document risk assessment every visit

Every psychiatric SOAP note should screen explicitly for suicidal and homicidal ideation, with both risk and protective factors. Note any change in risk status since the last visit and your reasoning. Example: "Acknowledges passive thoughts of 'not wanting to be here' but denies active ideation, plan, or intent. No history of attempts. Protective factors: connection to children, treatment engagement, safety plan agreed. Safety plan updated; patient contracted to call crisis line if thoughts worsen."

5. Justify every medication decision

Whenever you start, continue, adjust, or stop a medication, write why. Example: "Increasing escitalopram from 10 mg to 15 mg daily for partial response (GAD-7 down from 18 to 12) with good tolerability after 4 weeks. Discussed possible side effects including QT prolongation; benefits outweigh risks. Patient agreeable." This supports necessity and reduces liability.

Psychiatric Nursing Notes Example (SOAPIE)

On inpatient psychiatric units, nurses document the same patient from a nursing lens — often using the SOAPIE format, which adds Intervention and Evaluation to the standard SOAP structure. Here is a short psychiatric nursing notes example so you can see how the two records complement each other. For the full set of nursing formats (SOAPIE, DAR, focus, intake, group, shift, and incident notes), see our complete guide to psychiatric nursing notes.

Psychiatric Nursing Note — SOAPIE Example

S (Subjective): Patient stated, "I slept pretty good last night. I only woke up once," and "I'm ready for group today."
O (Objective): Awake and dressed at 0800, hair brushed, clean clothes. Smiled at greeting. Ate all of breakfast. Vitals: BP 118/76, HR 72, RR 16, Temp 98.6.
A (Assessment): Mood appears improved from yesterday, when patient was tearful and withdrawn. Reports good sleep and appetite. Engaging and positive.
P (Plan): Continue current medications. Encourage attendance at morning group. Offer one-to-one time after lunch to discuss discharge planning.
I (Intervention): Accompanied patient to morning coping-skills group at 0900. Met one-to-one at 1100 for 15 minutes on discharge planning.
E (Evaluation): Patient stayed for the full group and shared a coping skill. Identified a safe place to live after discharge and has a follow-up scheduled. States she feels ready for discharge.

What to Include and Exclude

A strong psychiatric SOAP note balances clinical completeness with patient privacy. Because the note is part of the official record, be deliberate about what goes in it.

Include

Relevant symptoms, behaviors, and statements that support the diagnosis
Risk assessment, including suicidal and homicidal ideation screening
Medication response, side effects, and adherence
Objective mental status and functioning
Assessment and treatment plan with a clear follow-up

Exclude

Details that could stigmatize the patient if the record were accessed
Your personal reactions to the patient that are not clinically relevant
Subjective judgments about character or personality
Speculative diagnoses without supporting evidence
Irrelevant personal details about the patient's life

Common Psychiatric SOAP Note Mistakes

Mixing observation with interpretation

"Patient was manipulative" is a judgment. "Patient asked three different staff for extra privileges within one hour" is an observation. Keep interpretation in Assessment, not Objective.

Skipping the risk assessment

A psych note without documented SI/HI screening is a liability gap. Even "denies suicidal and homicidal ideation" belongs in every note — a documented negative is protective.

A plan that doesn't match the assessment

If your Assessment notes worsening anxiety but the Plan makes no change and gives no rationale, a reviewer can't follow your reasoning. Every plan item should answer something in the Assessment.

Writing from memory hours later

The longer you wait, the more nuance you lose — and nuance is the whole point in psychiatry. Document during or immediately after the visit whenever you can.

Let an AI Scribe Write Your Psychiatric Notes

The hardest part of any psychiatric SOAP note is finding time to write it while staying fully present with the patient. That is exactly what an ambient AI scribe solves. Augustun for psychiatry listens during the encounter, understands the conversation, and drafts a complete, structured SOAP note — including a mental status exam, ICD-10 suggestions, and a clear plan — in seconds. You review, edit, and sign.

Augustun supports SOAP, SOAPIE, DAP, and BIRP formats, can draft treatment plans and patient instructions, and connects to 400+ EHRs through a simple browser extension so finished notes land where you already chart. It is built for clinical use with HIPAA compliance, and recordings are never stored.

Built for behavioral health

Whether you are documenting an intake, a med-management follow-up, or an inpatient encounter, Augustun adapts to your format. Comparing tools first? See our roundup of the best AI scribe for psychiatry.

Conclusion

The psychiatric SOAP note is more than paperwork — it is where your clinical reasoning becomes a record the rest of the team can act on. Keep the Subjective in the patient's words, let the Objective carry the mental status exam, make the Assessment show your diagnostic logic, and write a Plan that answers it. Add explicit risk and medication rationale every visit, and your notes will be faster to write, easier to defend, and genuinely useful to the next clinician.

Start from the template above, adapt one of the four examples to your patient, and build the habit. Whether you write them yourself or let an AI scribe draft them for you, clear psychiatric notes are one of the most valuable things you produce in a day.

Frequently asked questions

Do psychiatrists use SOAP notes?