SOAP notes are widely used by practitioners across many healthcare disciplines (including mental health) to document and organize findings in an objective way. Knowing exactly what to put in them can be tricky at times though. We hope this short guide will help you understand SOAP notes better and give you actionable tips for how to write them. We've included an example at the bottom.

SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the note. Let's look at each one.

Subjective

In the "Subjective" section of a SOAP note, healthcare providers record the patient's personal perspective of their condition, symptoms, and feelings. This is essentially what the patient says about their own experiences and concerns. It's the narrative part of the note where the patient's views, feelings, and thoughts about their mental health are documented.

In the context of mental health, the Subjective section might include:

• Patient's Description of Symptoms: How the patient describes their current symptoms (e.g., feelings of anxiety, depression, mood swings).
• Patient's Perception of Problem: The patient's understanding or interpretation of their mental health issues.
• Patient's Experience and History: Any relevant personal history or experiences that the patient shares which may be related to their current mental health status.
• Changes in Mood or Behavior: How the patient reports changes in their mood, thoughts, or behaviors since the last visit.
• Patient's Concerns and Goals: What the patient hopes to achieve through treatment or what concerns they might have.

This section is crucial for understanding the patient's perspective and forming a therapeutic relationship. It provides a context for the more objective clinical observations made by the healthcare provider in the subsequent sections of the SOAP note.

Many mental health practitioners focus on what’s known as a “Chief Complaint”(CC) or the presenting problem in this section. Here are some questions to ask to help uncover your client's Chief Complaint:

• Describe your symptoms in detail. When did they start and how long have they been going on?
• What is the severity of your symptoms and what makes them better or worse?
• What is your medical and mental health history?
• What other health-related issues are you experiencing?

Objective

The "O" in SOAP notes stands for "Objective." This section is where healthcare providers, including mental health professionals, record objective, observable, and measurable data about the patient. Unlike the Subjective section, which is based on the patient's personal experiences and feelings, the Objective section is based on facts and observations made by the healthcare provider.

In the context of mental health, the Objective section of a SOAP note might include:

• Mental Status Examination (MSE): This is a critical component in mental health documentation. It includes observations of the patient's appearance, behavior, speech, mood, affect (emotional expression), thought process, thought content (including any delusions or hallucinations), cognition (including memory and concentration), and insight/judgment.
• Physical Observations: Any relevant physical signs observed, such as hygiene, signs of self-harm, or physical agitation.
• Vital Signs: If relevant, this can include blood pressure, heart rate, and temperature. In some mental health settings, especially in cases involving medication management, these may be pertinent.
• Results of Diagnostic Tests: This could include outcomes from psychological tests, lab tests, or any other diagnostic procedures that have been performed.
• Quantitative Data: This can include the use of rating scales or questionnaires to assess symptoms (like depression or anxiety scales).

The Objective section is crucial for providing a clear, unbiased view of the patient's current status. It helps in forming a clinical assessment and developing an appropriate treatment plan. These observations should be factual and free from the personal interpretations or opinions of the healthcare provider.

Assessment

The "A" in SOAP notes stands for "Assessment." This section is a critical component in the documentation process, especially in the context of mental health. The Assessment part of the SOAP note is where the healthcare provider synthesizes the subjective and objective information gathered to form a professional clinical evaluation.

In the context of mental health, the Assessment section might include:

• Diagnosis or Differential Diagnosis: Based on the subjective reports from the patient and the objective findings (such as symptoms observed, results from mental status examinations, and any diagnostic tests), the clinician may identify a mental health diagnosis. If a clear diagnosis is not apparent, a differential diagnosis (considering various possible conditions that might explain the patient's symptoms) may be noted.
• Clinical Impressions: This involves the clinician's interpretation of the patient's condition, including insights into the nature and severity of the mental health issues.
• Evaluation of Progress: The clinician assesses the patient's progress or changes in symptoms since the last visit. This can include responses to treatment, changes in the severity of symptoms, or any new developments.
• Risk Assessment: Evaluation of any potential risks, such as harm to self or others, which is particularly important in mental health settings.
• Consideration of Contextual Factors: Assessment of how external factors, such as social, occupational, or educational contexts, are impacting the patient's mental health.

The Assessment section is essentially the clinician's professional interpretation and judgment about what all the gathered information means. It bridges the gap between what is reported and observed (in the Subjective and Objective sections) and the plan of action, which is outlined in the next section of the SOAP note. This assessment guides the direction of future therapy or interventions.

Plan

The "P" in SOAP notes stands for "Plan." This section outlines the healthcare provider's plan of action based on the assessment made in the previous section. In the context of mental health, the Plan section is particularly important as it details the proposed strategy for addressing the patient's mental health concerns and managing their care.

In the context of mental health, the Plan section might include:

• Treatment Plan: This includes the specifics of the mental health treatment approach that will be used. It may involve psychotherapy (such as cognitive-behavioral therapy, family therapy, etc.), pharmacotherapy (prescription of medications), or a combination of different therapeutic approaches.
• Medication Management: If medications are prescribed or adjusted, this should be detailed here, including the names of the medications, dosages, and instructions for use. Monitoring for side effects or potential interactions with other medications is also included.
• Referrals: If the patient needs services from other professionals or specialists (such as a psychiatrist for medication management, a psychologist for testing, or other health services), this should be noted.
• Psychoeducation: Providing information to the patient and possibly their family about the nature of the illness, treatment options, and coping strategies.
• Follow-up Schedule: This includes scheduling the next appointment or setting a timeline for the proposed interventions. It might also involve specifying certain milestones or checkpoints to assess the progress.
• Goals and Objectives: Setting short-term and long-term goals for therapy. These should be specific, measurable, achievable, relevant, and time-bound (SMART goals).
• Safety Plan: If there are concerns about the patient's safety (such as risk of self-harm or suicide), a safety plan should be developed. This might include emergency contact numbers, strategies to manage crisis situations, and steps to ensure the patient's safety.
• Coordination of Care: If necessary, this involves coordinating with other care providers, schools, or family members to ensure a comprehensive approach to treatment.

The Plan section is a critical part of the SOAP note as it provides a clear roadmap for how the healthcare provider intends to address the patient's mental health needs. It should be tailored to the individual patient and flexible enough to accommodate changes in the patient's condition or circumstances.

Example SOAP note

S (Subjective):

• Chief Complaint: The patient, a 30-year-old male, reports feeling "overwhelmed and anxious" for the past three months.
• History of Present Illness: He describes increased work stress, difficulty sleeping, and persistent worry about performance at work. He denies any substance use or past psychiatric history.
• Mood: The patient describes his mood as "generally low," with occasional periods of irritability.
• Patient's Goals: Expresses a desire to feel more in control and reduce anxiety.

O (Objective):

• Appearance: Well-groomed, appears stated age.
• Behavior: Cooperative, but visibly anxious; fidgeting during the session.
• Speech: Clear, coherent, but rapid at times.
• Mood and Affect: Anxious mood; affect congruent with mood.
• Thought Process: Logical and goal-directed.
• Thought Content: No evidence of delusions or suicidal ideation.
• Insight and Judgment: Insight is fair; judgment appears intact.

A (Assessment):

• The patient presents with symptoms consistent with Generalized Anxiety Disorder (GAD).
• Differential Diagnosis: Rule out Major Depressive Disorder and Adjustment Disorder.
• No immediate risk of harm to self or others identified.

P (Plan):

• Initiate Cognitive Behavioral Therapy (CBT) focused on anxiety management and coping strategies.
• Schedule weekly therapy sessions for the next two months.
• Consider referral to psychiatry for medication evaluation if symptoms do not improve or worsen.
• Encourage the patient to maintain a regular sleep schedule and engage in regular physical activity.
• Plan to reassess anxiety symptoms and treatment effectiveness in 4 weeks.
• Safety Plan: Provided emergency contact numbers and discussed steps to take in case of a crisis.

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