CBT for Chronic Pain Session Note (SOAP)

Patient: [name, MRN, DOB]

Date of Service: [date]

Provider: [name, credentials, signature]

Session: [number] of planned [total] | Phase/Module: [current focus]

Time: [start–stop or total minutes]

Modality: [in-person / telehealth: video / telehealth: audio-only] | Setting: [outpatient / pain clinic / integrated primary care / other]

Subjective

[Visit focus or patient's top concern for today] (One concise sentence.)

• Interval pain and function: [Pain pattern since last visit: baseline level, flares, triggers] [Sleep quality] [Medication or medical changes reported] [Functional interference in work, household tasks, mobility, social participation, and targeted meaningful activities] (Summarize only items reported today; emphasize functional impact over pain intensity.)
• Homework and skills practice: [What was assigned] [What was completed] [Barriers encountered] [Perceived effect of practice] [Brief direct quote capturing a key cognition or belief] (Include quote only if it captures a clinically relevant cognition such as catastrophizing or fear-avoidance.)
• Cognitive-behavioral patterns: [Observed patterns such as boom-bust pacing, avoidance, catastrophizing, changes in self-efficacy] (Use concise phrases; note changes from prior sessions.)
• Mood and safety: [Mood, anxiety, or substance use changes relevant to pain coping] [Safety screening results or disclosures with patient's words if positive] (Include only if assessed or indicated; otherwise state "not assessed" or "not indicated per clinic policy.")

Objective

• Observations: [Mental status findings: appearance, engagement, affect] [Visible pain behaviors] [Insight into pain-coping connection] (Clinician-observed findings only.)
• Measures: [Measure name] — [score], [date], [improved / stable / worsened vs prior] (If measures expected but not administered, state "not administered this session." Omit line entirely if measures are not part of clinic workflow.)
• Interventions delivered:
  • [Technique used] — [patient-specific example or context]; [participation level and skill acquisition or observed response]
  • (Add additional interventions as needed. Examples: agenda-setting, psychoeducation, pacing/quota-setting, behavioral activation, relaxation practice, cognitive restructuring, graded exposure, sleep strategies, flare plan work.)
• Materials provided: [Handouts, worksheets, app recommendations, or "none"]

Assessment

Diagnoses: [Behavioral health diagnoses] [Pain-related diagnostic framing, e.g., psychological factors affecting medical condition] (Do not introduce new medical diagnoses without appropriate evaluation.)

Formulation and progress: [Maintaining factors targeted: avoidance, catastrophizing, deconditioning] [How today's session addressed these factors] [Progress toward functional goals: behavioral evidence, measure trends, homework adherence, skill generalization] [Barriers or risk factors: flares, medical instability, environmental constraints]

Risk assessment: [Ideation, intent, plan, means, protective factors, safety plan actions] (Include when indicated or required by policy; otherwise state "not assessed—not indicated.")

Medical necessity: [Brief statement linking pain-related functional impairment to the need for skilled behavioral intervention and expected functional improvement or stabilization]

Plan

• Next session: [Planned focus] [Rationale] [Cadence: weekly / biweekly / other]
• Homework: [Specific skill practice with frequency and duration] [Recording method: logs, thought records, worksheets] (Be concrete, e.g., "diaphragmatic breathing 5 min 2x/day; log pre/post tension 0–10.")
• Pacing / graded activity plan: [Target activity] [Baseline tolerated dose] [Quota: time or repetitions] [Rest-break rules] [Progression criteria] [Medically-directed stop rules] (Include when pacing is an active treatment focus.)
• Flare plan: [Stepwise actions: regulate, reframe, pace, communicate, escalate] [When to contact medical providers] (Include when created or updated this session.)
• Coordination: [Communication with PCP, PT, pain clinic, or referrals placed] [ROI status] (Include when coordination occurred or is planned.)
• Follow-up: [Next appointment date/time or scheduling plan] [Crisis resources if safety concerns documented]

(Documentation rules: Always include date of service, provider, session time, modality, all four SOAP headings, at least one intervention with patient response, and homework. When an expected item is absent, use explicit statements such as "not assessed," "patient declined," or "not indicated." Do not leave blanks or insert placeholder-like clinical values. Acceptable inferences include clinician observations and brief formulations; do not invent unreported symptom severity or fabricate measure scores.)