Health Psychology Progress Note (SOAP)

Date of Service: [Date]

Patient: [Name or initials; ID if required]

Provider: [Name, degree/credentials]

Encounter Type: [Health Psychology follow-up / brief intervention]; [Setting: primary care / specialty clinic / other]

Modality: [in-person / video / telephone]

Time: [Total time: __ minutes / Start: __:__ — Stop: __:__] (Use site-required format for billing)

Reason for Visit: [One sentence summarizing behavioral/health focus and purpose]

Subjective

• [Chief concern and patient-stated priorities]
• [Interval medical/treatment changes since last visit] (Include data source if not patient report)
• [Current symptoms and functional impact relevant to health condition] (Mood, sleep, pain interference, fatigue, cognitive complaints as applicable)
• [Health behavior target(s) with barriers and facilitators] (e.g., medication adherence, CPAP use, dietary plan, exercise)
• [Response to prior intervention or homework practice]
• [Safety screening results] (Only if indicated: ideation, intent, plan, access to means, protective factors—brief summary)

Objective

Observations: [Salient behavioral observations: appearance, affect, engagement, thought process] (Include only clinically relevant changes; omit full MSE unless warranted)

Measures:

• [Instrument name]: [score] on [date] | [prior score] on [prior date] → [improving / stable / worsening] ([interpretation band if used])
• (Repeat for each measure administered; note reason if routinely tracked measure was omitted and clinically significant)

Intervention Delivered: [Intervention name using evidence-based terminology] (e.g., motivational interviewing, behavioral activation, problem-solving therapy, relaxation training, acceptance-based coping); [format/dose]; [patient engagement and response]; [barriers identified; teach-back results if applicable]

Assessment

[Brief clinical synthesis linking psychological/behavioral factors to the medical condition and current functioning; reference measure trends and functional examples] (1–2 short paragraphs)

[Risk level: low / moderate / high] (Only if assessed: include concise rationale, protective factors, and mitigation steps taken)

[Working diagnosis or diagnostic impression] (Avoid diagnosing solely from screening scores; frame uncertain impressions as hypotheses)

Plan

• [Problem/Behavioral target #1]: [Goal] — [Intervention/skill to practice]; [Monitoring: measure and timeframe]; [Care coordination if applicable]
• [Problem/Behavioral target #2]: [Goal] — [Intervention/skill]; [Monitoring]; [Care coordination] (Repeat as needed)
• [Patient homework]: [Concrete tasks with frequency and context for practice]
• [Follow-up]: [Timing], [Modality: in-person / video / telephone]; [Contingency instructions if symptoms worsen]
• [Safety plan status] (Only if created/updated: location stored and crisis resources provided)

(Omit sections or bullets not applicable. Use neutral, behaviorally descriptive language. Label data sources when relevant.)