CBT Session Progress Note (SOAP)

CBT Session Progress Note (SOAP)

(Use neutral, behaviorally anchored language suitable for an open medical record. This is a medical progress note, not a psychotherapy process note; avoid verbatim dialogue and countertransference content.)

Date of Service: [Date of service]

Session Time: [start–stop or total psychotherapy minutes]

Setting/Modality: [outpatient / telehealth / integrated primary care / other]

Subjective

[Chief concern in patient's words]

[Interval symptoms and functional impact since last session] (Summarize mood, anxiety, sleep, and relevant functioning. Include duration, frequency, severity, and impact if provided.)

CBT Homework Review: [Prior assignment, adherence level, barriers encountered, and patient-stated learnings]

Patient's View of Progress: [Patient-reported progress toward treatment goals]

Safety: [Denies / Endorses] [suicidal ideation / self-harm / homicidal ideation] (If endorsed, note briefly here; detailed Risk Assessment follows in Assessment section. If not assessed, state reason.)

Objective

Mental Status Exam: [Pertinent MSE findings: appearance, behavior, mood/affect, thought process/content, cognition, insight/judgment as relevant] (A focused MSE is acceptable when patient is stable.)

Measures: [Instrument name, score, and change from prior] (Note response to suicidality items if present. If expected measures were not completed, state reason.)

Observed Engagement: [Participation in session activities, skill demonstrations, behavioral indicators relevant to treatment]

Assessment

Diagnoses: [Active behavioral health diagnoses relevant to today's session]

Formulation: [Key maintaining factors, triggers, cognitive/behavioral patterns, and current treatment phase: psychoeducation / skill acquisition / exposure / relapse prevention]

Progress: [improved / stable / worsened] in [symptom severity / functioning / skill use / avoidance reduction] (Anchor to objective evidence or measures when available.)

Risk Assessment: (Include only when risk signal is present.) [Ideation, plan, intent, behaviors; risk and protective factors; overall level: low / moderate / high with rationale; specific mitigation steps] (Do not rely on safety contracts alone; document active mitigation.)

Plan

Interventions Today: [CBT techniques used and their targets] (e.g., cognitive restructuring for catastrophic thinking, exposure to avoided situation, behavioral activation)

Homework: [Specific, measurable between-session tasks with frequency and tools provided] (Note anticipated barriers and patient's stated readiness. If no homework assigned, document rationale.)

Coordination: [Communications with other providers or referrals placed, if applicable]

Follow-up: [Next appointment interval and modality] (If any risk present, include crisis plan and return precautions.)

Clinician Signature: [Name, credentials, date/time]