Geropsychology Psychotherapy Progress Note (SOAP)

Visit Information

Date of Service: [Date]

Psychotherapy Time: [start–stop times OR total face-to-face minutes] (Document psychotherapy time only; exclude non-psychotherapy activities. Time must support CPT code selection.)

Modality: [in-person / video / phone]

Participants: [patient alone / patient + caregiver / patient + family member] (If others present, specify relationship and note patient consent.)

Diagnoses/Target Symptoms: [primary psychiatric diagnosis; relevant secondary conditions; brief target symptom list]

Subjective

Chief Concern/Session Focus: [one-line anchor for today's session]

Interval History: [Concise update on mood/anxiety and triggers; sleep/energy/pain as relevant; cognitive changes from baseline; medication or medical events; social/functional changes; adherence to therapy homework and barriers. For geriatric patients, include changes in ADLs/IADLs or caregiver situation when relevant.]

Collateral Information: [informant name/relationship and key points] (Include only if collateral used; clearly distinguish from patient self-report.)

Objective

Mental Status: [appearance; behavior; psychomotor activity; speech; affect and observed mood; thought process; thought content; cognition as relevant including orientation, attention, insight/judgment] (Note accommodations used such as hearing amplification or written prompts. If assessment limited by modality or sensory barriers, state constraints.)

Measures: [scale name, score, date, brief interpretation] (Include only if administered or reviewed this session; otherwise omit.)

Assessment

Clinical Impression: [For each active problem addressed today: current severity and trajectory (improving/worsening/stable) with supporting evidence; functional impact and contributing factors. Include brief medical necessity statement linking symptoms to psychotherapy need.]

Risk: [suicide/self-harm ideation: denied / endorsed; homicide/violence ideation: denied / endorsed] (If positive or unclear, specify ideation characteristics, risk and protective factors, overall risk level, and actions taken. For older adults, address self-neglect, abuse/exploitation, or lethal means access when clinically relevant. If not assessed, state "not assessed" with rationale.)

Interventions:

• [intervention/technique] — [linked treatment goal]
• [intervention/technique] — [linked treatment goal]

(Specify techniques such as behavioral activation, cognitive restructuring, exposure work, problem-solving, relaxation training, skills rehearsal, psychoeducation, or caregiver coaching. Avoid vague statements like "supportive therapy provided.")

Response: [patient engagement; emotional/behavioral response during session; skill acquisition or barriers; progress toward treatment goals] (Note any accommodations made for sensory or cognitive limitations.)

Plan

Goals: [goals addressed today; next goals to address; goal modifications and rationale if any]

Homework: [1–2 specific between-session tasks with accommodations for sensory/cognitive limitations if needed]

Follow-up: [next appointment timing and modality]

Coordination/Referrals: [PCP/psychiatry communication, community resources, or other referrals] (Include only if applicable.)

Safety Plan: [updates to safety plan; crisis contacts; means safety steps] (Include only if risk elevated or plan updated this session.)

Signature: [clinician name, credentials, date/time]