SOAP Note (Therapy)

Subjective

[Subjective narrative] (Capture the visit’s content in one coherent paragraph using the encounter’s natural flow without imposing a fixed order. Include only details explicitly verbalized by the patient or clinician: the primary reason for today’s visit; onset/course since last visit; frequency, duration, severity; triggers/contexts if stated; relieving or exacerbating factors if stated; self-management attempts if stated; concrete impact on functioning at home/work/school if stated; associated symptoms only if explicitly mentioned; links to existing treatment goals only if explicitly referenced; patient’s stated goals, motivation, barriers, and adherence to agreed home practice or medications only if mentioned; any safety concerns disclosed—e.g., suicidal or violent thoughts, access to means, recent crises, protective factors—using the patient’s wording when quoted; and any relevant psychosocial, medical, or family context directly tied to the visit, such as recent stressors or supports, substance use, social determinants, medical conditions or medication effects impacting mental health, and family history if stated. Do not infer or solicit content not spoken.)

Objective

(Include only clinician-observed or clinician-measured facts stated aloud in the encounter. Patient-reported content belongs in Subjective. Clinician assessments and plans belong in A&P. List only items explicitly mentioned.)

• [Behavioral observations and mental status exam] (Only if explicitly mentioned. Use concise phrases for appearance, behavior, speech, mood/affect, thought process/content, perception, cognition/orientation/attention, insight/judgment. Emphasize changes from prior baseline if stated.)
• [In-session activities completed] (Only if explicitly mentioned. Examples: skills practice, worksheets, exposure steps, role-play; capture the concrete tasks done.)
• [Standardized measures reviewed] (Only if explicitly mentioned. Record instrument names and scores exactly as stated, e.g., “PHQ-9 [score]”, “GAD-7 [score]”.)
• [Collateral or records reviewed] (Only if explicitly mentioned. Summarize key facts from collateral contacts or documents referenced during the visit.)
• [Other objective facts] (Only if explicitly mentioned. Examples: care setting or telehealth modality and who was present, observable functional abilities, or non-psychiatric exam elements if performed.)

Assessment & Plan

(Summarize the clinician’s explicit impressions and next steps. Do not introduce patient-reported data here. Do not infer diagnoses or risks. Use only what the clinician states.)

[Problem 1]: [Diagnosis or clinical impression] (State the primary problem or focus of treatment as explicitly named by the clinician. In one concise paragraph, capture the clinician’s formulation: linkage between symptoms/function and the working impression, patient response to current interventions, progress toward goals, and current risk level only if explicitly stated. Include differentials only if explicitly stated.)

• [Plan elements] (Document plan items as short bullets in the order they were stated during the encounter. Include only items explicitly stated. Possible elements: specific psychotherapy techniques or strategies performed today; homework or skills practice with expected frequency/duration if stated; risk mitigation steps such as safety planning, means-restriction counseling, crisis resources; care coordination or referrals and purpose; follow-up timing and contingencies; medication considerations such as changes, monitoring, side effects, or coordination with a prescriber.)

[Problem 2]: [Diagnosis or clinical impression] (Include only if an additional issue was explicitly discussed. Summarize the clinician’s assessment as above.)

• [Plan elements] (Use the same approach: record plan items as short bullets in spoken order, limited to what was explicitly stated. Possible elements include those listed above.)

(Do not infer or include any information not explicitly stated in the transcript. Leave sections blank if information is not available.)