10 Common Psychiatry SOAP Note Examples

Create Your Psychiatry SOAP Note in 2 Minutes

Start with 3 free SOAP notes. No credit card required.

Type Your NoteRecord Note

List of cases

1. Major Depressive Disorder
2. Generalized Anxiety Disorder
3. Bipolar Disorder
4. Schizophrenia
5. ADHD Assessment
6. PTSD
7. Panic Disorder
8. OCD
9. Substance Use Disorder
10. Eating Disorder

1. Major Depressive Disorder

Description

The patient presents for follow-up of Major Depressive Disorder with medication management and therapy review.

SOAP Note

Patient Name: Sarah Johnson

Date of Visit: 09/01/2024

Subjective

Sarah Johnson, a 34-year-old female with MDD, presents for 1-month follow-up. Reports partial improvement in mood but continued anhedonia. Sleep improved to 6-7 hours with medication. Appetite remains decreased. Energy levels slightly better. Attending weekly therapy. Denies suicidal ideation. Work performance improving. Support system engaged.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 62 kg (stable)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Appropriate dress
    • Good eye contact
  • Behavior:
    • Cooperative
    • Psychomotor retardation improved
    • Normal speech rate/volume
  • Mood/Affect:
    • "Better but still struggling"
    • Affect more reactive
    • Appropriate range
  • Thought Process:
    • Linear
    • Goal-directed
    • No ruminations
  • Cognition:
    • Alert and oriented x3
    • Attention intact
    • Memory intact
• Assessment Tools:
  • PHQ-9: 12 (was 18)
  • GAD-7: 8
  • Columbia Suicide Scale: Negative

Assessment

1. Major Depressive Disorder, Recurrent
   • Partial response to treatment
   • No suicidal ideation
   • Functional improvement noted
2. Sleep Disturbance
   • Improved with medication
   • Continued monitoring needed

Plan

1. Treatment:

   • Medication adjustment
   • Continue therapy
   • Monitor response
   • CPT Code: 99214

2. Medications:

   • Increase sertraline to 150mg daily
   • Continue trazodone 50mg qhs
   • Consider adding bupropion

3. Psychotherapy:

   • Continue weekly CBT
   • Sleep hygiene review
   • Activity scheduling
   • Stress management

4. Follow-up:

   • 2 weeks follow-up
   • Continue therapy
   • Crisis plan reviewed

2. Generalized Anxiety Disorder

Description

The patient presents for initial evaluation of chronic anxiety symptoms affecting daily functioning.

SOAP Note

Patient Name: Michael Chen

Date of Visit: 09/02/2024

Subjective

Michael Chen, a 28-year-old male, presents with 6-month history of persistent anxiety, excessive worry, and difficulty controlling concerns about work, finances, and health. Reports muscle tension, restlessness, and difficulty concentrating. Sleep disrupted by racing thoughts. No prior psychiatric treatment. Family history of anxiety in mother.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 88 bpm
  • RR: 18/min
  • Temp: 98.6°F
  • Weight: 70 kg
• Mental Status Exam:
  • Appearance:
    • Neat, appropriate dress
    • Frequent fidgeting
    • Good eye contact
  • Behavior:
    • Cooperative
    • Psychomotor agitation
    • Rapid speech
  • Mood/Affect:
    • "Worried all the time"
    • Anxious affect
    • Full range
  • Thought Process:
    • Circumstantial
    • Preoccupied with worries
    • No delusions
  • Cognition:
    • Alert and oriented x3
    • Intact memory
    • Attention slightly impaired
• Assessment Tools:
  • GAD-7: 18
  • PHQ-9: 8
  • AUDIT: Negative

Assessment

1. Generalized Anxiety Disorder
   • Chronic symptoms
   • Significant impairment
   • No prior treatment
2. Insomnia
   • Secondary to anxiety
   • Affecting functioning

Plan

1. Treatment:

   • Initiate medication
   • Psychotherapy referral
   • Lifestyle modifications
   • CPT Code: 99204

2. Medications:

   • Start escitalopram 10mg daily
   • Hydroxyzine 25mg prn anxiety
   • Sleep hygiene education

3. Patient Education:

   • Anxiety management techniques
   • Breathing exercises
   • Sleep hygiene
   • Caffeine reduction

4. Follow-up:

   • 2 weeks follow-up
   • Therapy referral provided
   • Crisis resources given

3. Bipolar Disorder

Description

The patient presents for follow-up of Bipolar I Disorder with recent hypomanic symptoms.

SOAP Note

Patient Name: Jennifer Martinez

Date of Visit: 09/03/2024

Subjective

Jennifer Martinez, a 42-year-old female with Bipolar I Disorder, presents for follow-up after recent hypomanic episode. Reports improved sleep (now 6 hours/night), decreased irritability, and better impulse control. Mood more stable on current medication regimen. Denies suicidal/homicidal ideation. Support system involved. Attending group therapy weekly.

Objective

• Vital Signs:
  • BP: 122/78 mmHg
  • HR: 82 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 68 kg (stable)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Appropriate dress
    • Good eye contact
  • Behavior:
    • Cooperative
    • Normal psychomotor activity
    • Appropriate interactions
  • Mood/Affect:
    • "More balanced"
    • Euthymic affect
    • Full range
  • Speech:
    • Normal rate/volume
    • No pressured speech
    • Logical flow
  • Thought Process:
    • Linear
    • Goal-directed
    • No flight of ideas
  • Cognition:
    • Alert and oriented x3
    • Intact judgment
    • Good insight
• Assessment Tools:
  • YMRS: 8 (was 22)
  • PHQ-9: 6
  • MDQ: Positive

Assessment

1. Bipolar I Disorder
   • Recent hypomanic episode resolving
   • Good medication response
   • Improved insight
2. Sleep Pattern
   • Stabilizing
   • Medication adherent

Plan

1. Treatment:

   • Continue current medications
   • Monitor mood stability
   • Support system engagement
   • CPT Code: 99214

2. Medications:

   • Continue lithium 900mg daily
   • Continue quetiapine 300mg qhs
   • Continue propranolol 20mg BID

3. Psychotherapy:

   • Continue group therapy
   • Mood charting
   • Stress management
   • Sleep hygiene

4. Follow-up:

   • 2 weeks follow-up
   • Monthly lithium levels
   • Crisis plan updated

4. Schizophrenia

Description

The patient presents for routine follow-up of chronic schizophrenia with medication management.

SOAP Note

Patient Name: Robert Thompson

Date of Visit: 09/04/2024

Subjective

Robert Thompson, a 35-year-old male with chronic schizophrenia, presents for monthly follow-up. Reports stable symptoms with current medication regimen. Auditory hallucinations minimal. Paranoid thoughts decreased. Living in supervised housing. Participating in day program. Good medication adherence reported by case manager.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 84 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 82 kg (+2 kg)
  • BMI: 27.8
• Mental Status Exam:
  • Appearance:
    • Adequately groomed
    • Clean clothes
    • Fair eye contact
  • Behavior:
    • Cooperative
    • No abnormal movements
    • No agitation
  • Mood/Affect:
    • "Doing okay"
    • Restricted affect
    • Appropriate
  • Speech:
    • Normal rate/tone
    • Decreased spontaneity
    • Coherent
  • Thought Process:
    • Linear
    • Concrete thinking
    • No active delusions
  • Perceptions:
    • Minimal AH reported
    • No VH
    • No command hallucinations
  • Cognition:
    • Alert and oriented x3
    • Fair insight
    • Fair judgment
• Assessment Tools:
  • PANSS: 62 (stable)
  • AIMS: Negative
  • CGI: 3 (mildly ill)

Assessment

1. Schizophrenia, Chronic
   • Stable symptoms
   • Good medication adherence
   • Functional improvement
2. Metabolic Monitoring
   • Weight gain noted
   • Continued monitoring needed

Plan

1. Treatment:

   • Continue current medications
   • Monitor side effects
   • Support services
   • CPT Code: 99214

2. Medications:

   • Continue risperidone 4mg daily
   • Continue benztropine 1mg BID
   • Monitor metabolic effects

3. Psychosocial:

   • Continue day program
   • Case management
   • Social skills training
   • ADL support

4. Follow-up:

   • Monthly follow-up
   • Labs in 3 months
   • Continue case management

5. ADHD Assessment

Description

The patient presents for initial evaluation of suspected adult ADHD affecting work performance.

SOAP Note

Patient Name: David Wilson

Date of Visit: 09/05/2024

Subjective

David Wilson, a 29-year-old male software engineer, presents with lifelong history of attention difficulties, now significantly impacting work performance. Reports difficulty maintaining focus, frequent task-switching, procrastination, and disorganization. Symptoms present since childhood. School records show similar concerns. No prior psychiatric treatment. Denies substance use. Family history of ADHD in father.

Objective

• Vital Signs:
  • BP: 124/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 75 kg
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Casual attire
    • Frequent position changes
  • Behavior:
    • Cooperative
    • Fidgety
    • Easily distracted
  • Mood/Affect:
    • "Frustrated"
    • Full range
    • Appropriate
  • Speech:
    • Normal rate/volume
    • Occasionally tangential
    • Interactive
  • Thought Process:
    • Goal-directed
    • Jumps between topics
    • No thought disorder
  • Cognition:
    • Alert and oriented x3
    • Good insight
    • Intact judgment
• Assessment Tools:
  • ADHD-RS: 38/54
  • WURS: Positive
  • PHQ-9: 6
  • GAD-7: 8
• Collateral Information:
  • School records reviewed
  • Partner confirms symptoms
  • Work evaluations consistent

Assessment

1. Adult ADHD, Combined Type
   • Lifelong symptoms
   • Functional impairment
   • Meets DSM-5 criteria
2. Occupational Problems
   • Related to ADHD
   • Affecting performance

Plan

1. Treatment:

   • Initiate medication
   • Behavioral strategies
   • Workplace accommodations
   • CPT Code: 99204

2. Medications:

   • Start methylphenidate ER 18mg daily
   • Titrate based on response
   • Monitor vital signs

3. Psychosocial:

   • ADHD coaching referral
   • Organizational strategies
   • Time management skills
   • Workplace strategies

4. Follow-up:

   • 2 weeks follow-up
   • Medication monitoring
   • Behavioral plan review

6. PTSD

Description

The patient presents for follow-up of Post-Traumatic Stress Disorder related to combat experience.

SOAP Note

Patient Name: James Miller

Date of Visit: 09/06/2024

Subjective

James Miller, a 45-year-old male veteran, presents for follow-up of PTSD. Reports modest improvement in nightmares with prazosin. Continues to experience hypervigilance and startle response. Attending VA support group. Sleep averaging 5-6 hours. Flashbacks decreased in frequency. Avoiding crowded places. Support from family helpful.

Objective

• Vital Signs:
  • BP: 132/84 mmHg
  • HR: 78 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 80 kg (stable)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Military bearing
    • Guarded posture
  • Behavior:
    • Cooperative
    • Hypervigilant
    • Scans room
  • Mood/Affect:
    • "Managing better"
    • Constricted affect
    • Appropriate
  • Speech:
    • Normal rate/tone
    • Clear and coherent
    • Goal-directed
  • Thought Process:
    • Linear
    • No delusions
    • Combat memories intrusive
  • Cognition:
    • Alert and oriented x3
    • Good insight
    • Intact judgment
• Assessment Tools:
  • PCL-5: 45 (was 58)
  • PHQ-9: 12
  • GAD-7: 14
  • AUDIT: Negative

Assessment

1. PTSD, Combat-Related
   • Partial response to treatment
   • Ongoing hyperarousal
   • Improved sleep
2. Depression, Secondary
   • Moderate symptoms
   • Treatment responsive

Plan

1. Treatment:

   • Continue medications
   • Monitor symptoms
   • Support system engagement
   • CPT Code: 99214

2. Medications:

   • Continue sertraline 200mg daily
   • Increase prazosin to 4mg qhs
   • Continue propranolol 20mg prn

3. Psychotherapy:

   • Continue VA support group
   • Trauma-focused CBT
   • Relaxation techniques
   • Sleep hygiene

4. Follow-up:

   • 3 weeks follow-up
   • Continue group therapy
   • Crisis plan reviewed

7. Panic Disorder

Description

The patient presents for follow-up of Panic Disorder with recent increase in frequency of attacks.

SOAP Note

Patient Name: Emily Rodriguez

Date of Visit: 09/07/2024

Subjective

Emily Rodriguez, a 32-year-old female with Panic Disorder, presents for follow-up. Reports increase in panic attacks from 1-2/month to 2-3/week over past month. Attacks include racing heart, shortness of breath, dizziness, and fear of dying. Duration typically 15-20 minutes. Identifies work stress as trigger. Using clonazepam as prescribed. Attending therapy regularly.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 88 bpm
  • RR: 18/min
  • Temp: 98.6°F
  • Weight: 65 kg (stable)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Appropriate dress
    • Anxious demeanor
  • Behavior:
    • Cooperative
    • Mildly restless
    • Normal movements
  • Mood/Affect:
    • "On edge"
    • Anxious affect
    • Full range
  • Speech:
    • Normal rate/volume
    • Clear and coherent
    • Goal-directed
  • Thought Process:
    • Linear
    • Focus on symptoms
    • No delusions
  • Cognition:
    • Alert and oriented x3
    • Good insight
    • Intact judgment
• Assessment Tools:
  • PDSS: 14 (was 8)
  • GAD-7: 16
  • PHQ-9: 10
  • BAI: 24

Assessment

1. Panic Disorder
   • Increased frequency
   • Identifiable triggers
   • Treatment engaged
2. Generalized Anxiety
   • Secondary to panic
   • Affecting functioning

Plan

1. Treatment:

   • Medication adjustment
   • Continue therapy
   • Stress management
   • CPT Code: 99214

2. Medications:

   • Increase sertraline to 150mg daily
   • Continue clonazepam 0.5mg prn
   • Consider propranolol prn

3. Psychotherapy:

   • Continue CBT
   • Panic management skills
   • Breathing exercises
   • Progressive relaxation

4. Follow-up:

   • 2 weeks follow-up
   • Daily symptom tracking
   • Crisis plan reviewed

8. OCD

Description

The patient presents for initial evaluation of obsessive-compulsive symptoms affecting daily functioning.

SOAP Note

Patient Name: Thomas Anderson

Date of Visit: 09/08/2024

Subjective

Thomas Anderson, a 25-year-old male, presents with 2-year history of intrusive thoughts about contamination and compulsive hand washing. Washing hands 30-40 times daily until "feels right." Spends 3-4 hours daily on cleaning rituals. Significant distress and social impairment. No prior treatment. Family history of anxiety disorders. Denies suicidal ideation.

Objective

• Vital Signs:
  • BP: 122/74 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 72 kg
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Chapped hands
    • Anxious demeanor
  • Behavior:
    • Cooperative
    • Frequent hand sanitizer use
    • Checking behaviors
  • Mood/Affect:
    • "Trapped"
    • Anxious affect
    • Appropriate range
  • Speech:
    • Normal rate/volume
    • Clear and coherent
    • Occasional rumination
  • Thought Process:
    • Preoccupied with contamination
    • Insight into irrationality
    • No thought disorder
  • Cognition:
    • Alert and oriented x3
    • Fair insight
    • Intact judgment
• Assessment Tools:
  • Y-BOCS: 28
  • GAD-7: 18
  • PHQ-9: 12
  • OCI-R: 32

Assessment

1. Obsessive-Compulsive Disorder
   • Severe symptoms
   • Significant impairment
   • No prior treatment
2. Secondary Depression
   • Moderate symptoms
   • Related to OCD impact

Plan

1. Treatment:

   • Initiate medication
   • ERP therapy referral
   • Psychoeducation
   • CPT Code: 99204

2. Medications:

   • Start fluoxetine 20mg daily
   • Titrate as tolerated
   • Target dose 60-80mg

3. Psychotherapy:

   • ERP therapy referral
   • CBT principles
   • Family education
   • Support group info

4. Follow-up:

   • 2 weeks follow-up
   • Weekly therapy
   • Symptom monitoring

9. Substance Use Disorder

Description

The patient presents for follow-up of Alcohol Use Disorder in early remission, participating in outpatient treatment program.

SOAP Note

Patient Name: Richard Cooper

Date of Visit: 09/09/2024

Subjective

Richard Cooper, a 42-year-old male with Alcohol Use Disorder, presents for follow-up at 60 days of sobriety. Reports strong cravings but maintaining abstinence. Attending AA meetings daily. Completed IOP program. Sleep improving. Mood stable. Family supportive. Working with sponsor. Identifies evening hours as highest risk for relapse.

Objective

• Vital Signs:
  • BP: 124/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 82 kg (+2 kg)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Casual dress
    • Good eye contact
  • Behavior:
    • Cooperative
    • Engaged
    • Appropriate
  • Mood/Affect:
    • "More hopeful"
    • Full range
    • Appropriate
  • Speech:
    • Normal rate/volume
    • Clear and coherent
    • Open discussion
  • Thought Process:
    • Linear
    • Goal-directed
    • Future-oriented
  • Cognition:
    • Alert and oriented x3
    • Good insight
    • Improved judgment
• Assessment Tools:
  • AUDIT: 0 (was 28)
  • PHQ-9: 6
  • GAD-7: 8
  • CIWA: 0
• Laboratory:
  • GGT: 45 (improved)
  • AST/ALT: WNL
  • CDT: Negative

Assessment

1. Alcohol Use Disorder
   • Early remission
   • Treatment engaged
   • Strong recovery focus
2. Anxiety
   • Mild symptoms
   • Coping skills improving

Plan

1. Treatment:

   • Continue current plan
   • Relapse prevention
   • Support engagement
   • CPT Code: 99214

2. Medications:

   • Continue naltrexone 50mg daily
   • Continue gabapentin 300mg TID
   • Continue thiamine

3. Psychosocial:

   • Continue AA meetings
   • Sponsor relationship
   • Family therapy
   • Stress management

4. Follow-up:

   • 2 weeks follow-up
   • Continue IOP aftercare
   • Labs in 3 months

10. Eating Disorder

Description

The patient presents for follow-up of Anorexia Nervosa in partial remission with ongoing monitoring.

SOAP Note

Patient Name: Lauren Mitchell

Date of Visit: 09/10/2024

Subjective

Lauren Mitchell, a 20-year-old female with Anorexia Nervosa, presents for monthly follow-up. Reports maintaining meal plan with occasional anxiety. Weight stable. Attending group therapy weekly. Using CBT skills for food-related anxiety. Exercise within prescribed limits. Family supportive. College courses going well.

Objective

• Vital Signs:
  • BP: 110/68 mmHg
  • HR: 62 bpm
  • RR: 16/min
  • Temp: 98.2°F
  • Weight: 52.5 kg (stable)
  • BMI: 19.2
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Appropriate dress
    • Normal gait
  • Behavior:
    • Cooperative
    • Engaged
    • Less body checking
  • Mood/Affect:
    • "More confident"
    • Broader affect
    • Appropriate
  • Speech:
    • Normal rate/volume
    • Clear and coherent
    • Less food focus
  • Thought Process:
    • Linear
    • Less rigid
    • Future-oriented
  • Cognition:
    • Alert and oriented x3
    • Improving insight
    • Better judgment
• Assessment Tools:
  • EAT-26: 15 (was 38)
  • PHQ-9: 8
  • GAD-7: 10
  • Body image assessment improved
• Laboratory:
  • CBC: WNL
  • CMP: WNL
  • TSH: Normal
  • EKG: Normal sinus rhythm

Assessment

1. Anorexia Nervosa
   • Partial remission
   • Weight maintained
   • Treatment engaged
2. Anxiety
   • Food-related
   • Improving with CBT

Plan

1. Treatment:

   • Continue current plan
   • Monitor progress
   • Support engagement
   • CPT Code: 99214

2. Medications:

   • Continue fluoxetine 40mg daily
   • Continue olanzapine 2.5mg qhs
   • Continue multivitamin

3. Psychotherapy:

   • Continue group therapy
   • CBT skills practice
   • Body image work
   • Family support

4. Follow-up:

   • Monthly follow-up
   • Weekly weights
   • Continue monitoring