Psychotherapy Session Progress Note (SOAP)

Psychotherapy Progress Note (SOAP)

(This is a clinical progress note for treatment continuity, risk management, and billing. Do not include psychotherapy process content or private analytic reflections; maintain such material separately per HIPAA.)

Session Information

• Patient: [name, MRN]
• DOB: [date of birth]
• Date of Service: [date]
• Session Time: [start time – end time] or [total psychotherapy minutes]
• Provider: [name, credentials]
• Session Type: [individual / family / couples]
• Modality: [in-person / telehealth (audio-video) / telehealth (audio-only)]
• Diagnosis: [diagnosis or diagnoses addressed this session]

(If telehealth:) Telehealth documentation: Patient location: [location]. Consent confirmed: [yes / no]. Emergency contact/plan verified: [yes / no; details if no].

Subjective

[Chief concern or primary focus of today's session]

[Interval symptoms and functioning since last session, including relevant changes in mood, sleep, energy, concentration, relationships, or daily activities; salient stressors or life events; therapy homework completion or barriers; medication adherence or side effects if relevant]

• Risk screening: (Document actual assessment; avoid boilerplate "denies SI/HI" unless explicitly assessed.)
  • Suicidal ideation: [none / passive / active; include plan, intent, timeline if present]
  • Self-harm: [none / urges / behaviors; specify if present]
  • Homicidal ideation: [none / present; specify if present]
  • Access to lethal means: [no / yes; describe and note means-safety status if risk present]
  • (If not assessed: [reason and alternative steps taken])

Objective

(Document observable mental status findings with brief descriptors; avoid "WNL" alone.)

• Appearance/behavior: [grooming, cooperation, eye contact]
• Psychomotor activity: [normal / slowed / agitated]
• Speech: [rate, volume, prosody]
• Mood (patient's words): "[verbatim]"
• Affect: [range, intensity, congruence]
• Thought process: [linear / circumstantial / tangential / disorganized]
• Thought content: [pertinent findings or "no delusions, obsessions, or perceptual disturbances reported"]
• Cognition: [orientation, attention, memory as relevant]
• Insight/judgment: [brief descriptors]
• (Assessment limitations: [e.g., audio-only, technical issues, abbreviated duration] — only if applicable)
• (Standardized measures: [instrument, score, trend] — only if administered)

Assessment

[Clinical synthesis linking current presentation to diagnoses and treatment goals; progress toward specific goals with behavioral examples; setbacks or barriers; response to today's interventions]

• Risk assessment: Overall level: [low / moderate / high], [acute / chronic]. Rationale: [risk factors], [protective factors], [plan/intent/means status]. Higher level of care considered: [yes / no; brief rationale].
• Medical necessity: [Brief rationale for continued psychotherapy at current frequency, tied to functional impairment and treatment needs]

Plan

• Interventions today: [modality and techniques used, e.g., CBT cognitive restructuring, DBT distress tolerance, motivational interviewing; patient engagement and response]
• Between-session practice: [homework or skills to practice; frequency; anticipated barriers]
• Safety plan: [plan reviewed/updated; means-safety counseling; crisis resources provided] (Include only if risk present.)
• Coordination: [referrals, collateral contacts, or communications with other providers] (Include only if applicable.)
• Follow-up: [next appointment date], [modality], [frequency]. Contingency: [instructions if symptoms worsen or crisis occurs].

(Use neutral, behaviorally anchored language. Include only information relevant to diagnosis, risk, treatment goals, and plan. Do not infer details not explicitly assessed or reported.)