Hypnotherapy Session Note (SOAP)

Date/Time: [date of service, start and stop times]

Provider: [name and credentials]

Session: [number in episode, e.g., "Session 4 of planned 8"]

Visit Type: [in-person / telehealth; location]

Participants: [patient alone / others present with relationship]

Subjective

[Chief concern for today's session] (Open with today's primary focus; optionally include one brief direct quote. State interval since last visit and describe changes in target symptoms, severity, triggers, or functional impact.)

Home Practice: [assignment from last session, frequency practiced, perceived benefit, barriers or adverse experiences] (If not assigned or not reviewed, state "None assigned" or "Not reviewed.")

Risk Screening: [findings if assessed] (Only document "denies SI/HI" if explicitly assessed. If not assessed, state "Not assessed today.")

Consent/Readiness: [patient confirms readiness and verbal consent for hypnosis; note any preferences or concerns]

Objective

Mental Status: [appearance, behavior, speech, mood/affect, thought process, cognition, insight/judgment as pertinent] (Brief narrative of relevant observations.)

Hypnosis Intervention: [induction method, deepening techniques, therapeutic suggestions delivered with clinical rationale, emergence/reorientation method, patient status at conclusion] (Describe approach without verbatim scripts. If hypnosis was not performed, state "No hypnosis conducted today" with brief rationale.)

Patient Response: [observed engagement and depth markers, subjective report of experience, pre/post metrics if obtained, adverse responses and interventions] (If no adverse responses, state "None observed.")

Assessment

[Clinical synthesis and progress toward treatment goals compared to prior session, with supporting evidence] (Offer bounded interpretation of response to hypnosis without overstating causality. Include risk level and rationale if risk factors present. Briefly state medical necessity linking symptoms to continued treatment.)

Plan

Home Practice: [specific assignment, frequency/duration, troubleshooting guidance, materials provided]

Next Session: [planned focus and anticipated approach]

Coordination: [referrals or communication with other providers] (If none, state "None" or omit.)

Follow-up: [date/time or recommended interval]

Total Session Time: [minutes] (Ensure documentation supports billed service code.)