Medically Reviewed: Dr Hanif Chatur
Image Credits: Canva
Introduction
SOAP notes are very important for mental health professionals in documenting the patient’s progress in an orderly and efficient way. A well-written SOAP note Example is a gateway toward clear expression of the information, precision, and continuity of care. In conducting your Mental Status Exam, writing hospital emergency discharge notes, or even preparing a biopsychosocial assessment, SOAP notes assist in using the same consistent professional approach to therapy documentation.
In this guide, we’ll explore an ideal SOAP note example in mental health, covering best practices and tips to enhance your therapy notes.
What is a SOAP Note?
Structured in a four-part standard for medical note-taking on patient information are SOAP notes:
- Subjective (S): Symptoms and complaints of patient as related by patient.
- Objective (O): Observable findings or data from assessment by a clinician, for example Mental Status Exam findings.
- Assessment (A): The clinician’s analysis of the patient’s state, for example, anxiety disorder ICD-10 (F41.9), PTSD ICD-10 (F43.10).
- Plan (P): Next steps in treatment-any treatment plan for anxiety, for example, or interventions.
SOAP Note Example in Mental Health
Subjective (S)
This section records the patient’s reported symptoms, feelings, and experiences.
📝 Example:
“The patient reports persistent anxiety, difficulty sleeping, and racing thoughts. They feel overwhelmed by work responsibilities and have trouble concentrating.”
Objective (O)
This section includes measurable clinical observations, such as behaviors and Mental Status Exam results.
📝 Example:
“The patient appears restless, with noticeable fidgeting. Speech is rapid but coherent. Eye contact is inconsistent, and mood appears anxious.”
Assessment (A)
Here, the clinician provides an analysis based on observed symptoms and biopsychosocial assessments.
📝 Example:
“The patient presents symptoms consistent with GAD ICD-10 (F41.1). Anxiety symptoms impact daily functioning, warranting further intervention through therapy.”
Plan (P)
The Plan section outlines recommendations and next steps for treatment.
📝 Example:
“Continue with weekly therapy sessions focusing on cognitive-behavioral techniques. Patient advised to practice mindfulness exercises. Re-evaluate in four weeks.”
Best Practices for Writing Effective SOAP Notes
✔ Be Concise & Clear – Use direct language to maintain clarity in therapy notes.
✔ Use Standardized Terminology – Implement structured note formats like DAP notes or BIRP notes.
✔ Align with Treatment Plans – Ensure SOAP notes reflect the patient’s treatment plan for anxiety or other mental health concerns.
✔ Ensure Confidentiality – Protect patient information in compliance with medical privacy laws.
✔ Utilize Templates – Tools like SOAP note template mental health PDF can help maintain consistency.
Final Thoughts
Writing structured and effective SOAP notes is crucial for mental health professionals. Whether documenting a therapy intake, preparing hospital emergency discharge notes, or conducting a Mental Status Exam, clear and organized notes enhance patient care.
By following the SOAP note example in mental health outlined above and integrating standardized formats like BIRP notes and DAP notes, professionals can improve documentation quality while ensuring a structured approach to patient progress tracking.
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