Pediatric Psychology Progress Note (SOAP)

Date of Service: [Date]

Provider: [Provider name, credentials; supervising clinician if trainee]

Setting/Modality: [outpatient therapy / specialty clinic follow-up / brief consult follow-up]; [in-person / video / phone]

Participants: [patient; caregiver(s) present; interpreter if used]

Session Time: [start time–stop time or total direct treatment minutes] (Required for billing; if exact times unavailable, document why and what was used instead.)

Subjective

[Reason for visit or session focus] (Open with one concise line naming the primary treatment target.)

[Interval changes since last contact] (Summarize symptom status, relevant functioning, treatment adherence including skill practice and barriers, and significant events. Include caregiver perspective when relevant. Use brief direct quotes only if they capture key clinical content.)

Risk/Safeguarding: [Suicidal ideation / self-harm / homicidal ideation / abuse–neglect concerns: endorsed / denied] (Include when clinically indicated by age, presentation, or policy. If not assessed, state why. If endorsed, note ideation characteristics, protective factors, and supervision status.)

Objective

Behavioral Observations: [Pertinent mental status findings by relevant domains] (Include only domains relevant to presentation. Note observation limits if applicable.)

Measures: [Measure name, informant, score, interpretation, and trend if available] (Include only if administered. If attempted but not completed, note the barrier. Omit if none administered.)

Interventions Delivered: [Therapeutic approach and treatment target; what occurred in session with sufficient specificity; developmental adaptations or interactive complexity factors if applicable] (Specify techniques used—e.g., psychoeducation topic, exposure steps, skill rehearsed, parent coaching provided. Avoid vague phrases like "supportive therapy.")

Patient/Caregiver Response: [Participation, comprehension, skill demonstration, affect changes, and barriers encountered]

Assessment

[Clinical synthesis connecting today's findings to diagnostic impressions and functional status; progress toward treatment goals as improving / unchanged / worsening with one supporting data point]

Diagnoses: [Primary and secondary diagnoses with codes if required]

Risk Assessment: [Risk level: low / moderate / high]; [rationale]; [actions taken] (Include only if risk was assessed or concerns present. Document safety plan updates, means restriction counseling, crisis resources reviewed, or mandated report if applicable.)

Medical Necessity: [Symptoms or impairments justifying continued treatment and appropriateness of current modality/frequency]

Plan

• Next session focus: [Planned focus and any change to approach]
• Homework/practice: [Specific skill or task assigned; frequency; tracking method]
• Caregiver tasks: [Reinforcement strategies, monitoring, or environmental supports] (Omit if not applicable.)
• Coordination: [Communication with PCP, psychiatry, school; authorization status] (State "none today" if none needed.)
• Safety plan/crisis instructions: [Plan location, crisis numbers, escalation thresholds, supervision steps] (Include only if risk present.)
• Follow-up: [Next visit timing and modality; contingency for worsening]
• Billing attestation: [Total direct minutes restated]; [individual / family / parent-only]; [CPT code(s) and add-on rationale if applicable]

(Keep note concise and behaviorally specific. Omit elements not relevant to today's encounter. Avoid copy-forward content without verification.)