Rehabilitation Psychology SOAP Note

Date of Service: [Date]

Location/Setting: [Location and setting]

Visit Type: [individual / family / co-treatment / group]

Modality: [in-person / telehealth audio-video / telehealth audio-only] (If telehealth, document patient location and consent per policy.)

Clinician: [Name, credentials]

Time: [Start–Stop times or total face-to-face minutes]

Participants: [Patient]; [Family/caregiver with relationship]; [Interpreter and language, if used]; [Team members present]

Reason for Contact: [One-line summary of session focus aligned to rehab goals] (Do not include psychotherapy process content.)

Subjective

[Patient-stated priority or chief concern] (Begin with this in one concise sentence; attribute source.) [Interval history since last contact affecting coping/behavior and participation: relevant medical events, psychosocial changes, treatment adherence, changes in supports or environment] (Attribute sources: per patient / per family / per chart / per team.)

[Patient-reported symptoms relevant to rehabilitation psychology: mood, anxiety, sleep, fatigue, pain experience and coping strategies] [Rehabilitation participation since last visit: engagement in PT/OT/SLP, barriers, motivation, functional concerns, strategy/homework carryover] (Use behaviorally specific descriptors; avoid clinician interpretation here. If patient cannot reliably report due to aphasia, cognitive impairment, or sedation, state limitation and identify alternate sources used.)

Objective

• Behavioral observations: [Alertness/orientation; engagement; cooperation; psychomotor activity; observed therapy-interfering behaviors; pain behaviors; use of communication/cognitive supports]
• Mental Status (focused): [Appearance; speech; mood/affect; thought process/content; cognition; insight/judgment] (Only include domains assessed this visit; use behaviorally anchored descriptors.)
• Risk/Safety: [Suicidal ideation screening result] (Always include.) (If positive: include frequency, plan, intent, means; protective factors; clinical risk level; mitigation steps taken. If screening indicated but not completed, state reason and plan to reassess.)
• Standardized measures: [Measure name, date, score, and brief interpretation] (Include if administered this visit.)

Assessment

• [Problem/Diagnosis 1]: [Working diagnosis or targeted rehabilitation-psychology problem; brief biopsychosocial formulation linking psychological factors to rehab participation and functional outcomes; progress toward goals and response to prior interventions] (Note if diagnosis is provisional with brief differential reasoning.)
• [Problem/Diagnosis 2]: [Additional problem if addressed this visit; formulation and functional impact; progress] (Include only problems actively addressed.)

Medical necessity: [One-line statement connecting current symptoms/behavioral barriers to functional impact and the need for psychologist-delivered intervention]

Plan

• Interventions provided today: [Intervention type and linked clinical target] (Use behaviorally specific descriptors; avoid psychotherapy process content.)
• Patient response: [Engagement level; comprehension; skill acquisition evidence; observable affect/behavior change; barriers encountered]
• Homework/home program: [Concrete behavioral tasks with frequency, duration, and context; materials provided]
• Next session focus and frequency: [Planned focus; recommended frequency; criteria for discharge or level-of-care change]
• Coordination/communication: [Team consults; recommendations for rehab disciplines; caregiver contact and guidance provided]
• Safety plan: [If risk identified: immediate safety actions, means restriction, coping steps, crisis resources, notifications, escalation steps] (If no acute risk, state screening negative.)
• Follow-up: [Date/timeframe of next contact]

(Style guidance: Attribute all information sources; use person-first, non-stigmatizing, behaviorally specific language; avoid verbatim dialogue and therapist reflections; ensure each note reflects the unique encounter.)