10 Common Psychotherapy SOAP Note Examples
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List of cases
- Anxiety Disorders
- Depression
- Post-Traumatic Stress Disorder (PTSD)
- Obsessive-Compulsive Disorder (OCD)
- Bipolar Disorder
- Schizophrenia
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Eating Disorders
- Substance Use Disorders
- Personality Disorders
1. Anxiety Disorders
Description
The patient reports persistent feelings of anxiety and worry that interfere with daily activities. Symptoms include restlessness, fatigue, difficulty concentrating, and sleep disturbances.
SOAP Note
Patient Name: Alex Johnson
Date of Visit: 09/01/2024
Subjective
Alex Johnson presents with a chief complaint of persistent anxiety and worry that have been present for several months. He describes feeling restless and fatigued, with difficulty concentrating and sleep disturbances. Alex rates his anxiety as 7 out of 10 on a scale of severity. He reports that these symptoms interfere with his work performance and social interactions. Alex has tried mindfulness exercises and over-the-counter supplements with minimal relief. He has no previous history of anxiety disorders and is not currently taking any prescribed medications. Alex's primary goal is to reduce his anxiety and improve his overall quality of life.
Objective
- Appearance:
- Neatly dressed, good hygiene
- Behavior:
- Cooperative, but appears tense
- Mood/Affect:
- Anxious mood, restricted affect
- Speech:
- Normal rate and volume
- Thought Process:
- Logical and coherent
- Cognition:
- Alert and oriented to person, place, and time
Assessment
Alex presents with symptoms indicative of generalized anxiety disorder. His primary functional limitations include difficulty concentrating and sleep disturbances, which affect his work and social life. The absence of previous anxiety disorders and the chronic nature of his symptoms suggest a need for structured psychotherapy. Alex's motivation to improve his quality of life is a positive prognostic factor. The plan includes cognitive-behavioral therapy (CBT) to address anxiety symptoms, relaxation techniques to manage stress, and education on lifestyle modifications to support mental health. Follow-up appointments will be necessary to monitor progress and adjust the treatment plan as needed.
Plan
-
Cognitive-Behavioral Therapy (CBT):
- Focus on identifying and challenging negative thought patterns
- Develop coping strategies to manage anxiety
-
Relaxation Techniques:
- Practice deep breathing exercises and progressive muscle relaxation
- Frequency: Daily practice, 10-15 minutes per session
-
Lifestyle Modifications:
- Encourage regular physical activity and a balanced diet
- Discuss the importance of sleep hygiene and stress management
-
Patient Education:
- Educate Alex on the nature of anxiety disorders and the benefits of therapy
- Provide resources for additional support, such as support groups or online forums
-
Follow-Up:
- Schedule weekly therapy sessions for the next 8 weeks
- Re-evaluate Alex's condition and progress at each session, and modify the treatment plan as needed
ICD-10 Code: F41.1 (Generalized anxiety disorder)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
2. Depression
Description
The patient presents with symptoms of major depressive disorder, including persistent sadness, loss of interest in activities, changes in sleep and appetite, and difficulty concentrating.
SOAP Note
Patient Name: Sarah Martinez
Date of Visit: 09/02/2024
Subjective
Sarah Martinez presents with symptoms of depression that have persisted for the past three months. She reports feeling sad and hopeless most days, with a significant decrease in interest in previously enjoyable activities. Sarah describes changes in her sleep pattern (sleeping 10-12 hours but still feeling tired), decreased appetite with a 10-pound weight loss, and difficulty concentrating at work. She rates her depression as 8 out of 10 in severity. Sarah denies any current suicidal ideation but acknowledges occasional passive thoughts of "not wanting to wake up." She has no previous history of depression and is not currently taking any medications. Her primary goal is to regain her sense of joy and motivation in life.
Objective
- Appearance:
- Casually dressed, slightly disheveled
- Behavior:
- Cooperative but withdrawn
- Mood/Affect:
- Depressed mood, flat affect
- Speech:
- Slow rate, soft volume
- Thought Process:
- Linear and coherent
- Cognition:
- Alert and oriented, with some difficulty concentrating
Assessment
Sarah presents with symptoms consistent with major depressive disorder. Her symptoms significantly impact her daily functioning, particularly in areas of work performance, self-care, and social relationships. The recent onset of symptoms without prior history suggests potential environmental triggers that need to be explored. Sarah's insight into her condition and willingness to seek help are positive prognostic factors. The treatment plan will focus on a combination of cognitive-behavioral therapy, behavioral activation, and possible referral for medication evaluation if symptoms persist.
Plan
-
Cognitive-Behavioral Therapy (CBT):
- Address negative thought patterns and cognitive distortions
- Develop healthy coping mechanisms
-
Behavioral Activation:
- Create a structured daily routine
- Gradually reintroduce pleasurable activities
- Set small, achievable goals
-
Safety Planning:
- Develop a crisis plan
- Provide emergency contact numbers
- Schedule check-ins as needed
-
Lifestyle Modifications:
- Encourage regular exercise
- Establish healthy sleep habits
- Implement proper nutrition practices
-
Follow-Up:
- Schedule twice-weekly sessions for the first month
- Monitor symptoms and adjust treatment plan as needed
- Consider psychiatric referral if symptoms don't improve
ICD-10 Code: F32.1 (Major depressive disorder, single episode, moderate)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
3. Post-Traumatic Stress Disorder (PTSD)
Description
The patient presents with symptoms of PTSD following a car accident six months ago, including intrusive memories, nightmares, hypervigilance, and avoidance behaviors.
SOAP Note
Patient Name: Michael Chen
Date of Visit: 09/03/2024
Subjective
Michael Chen presents with symptoms of PTSD following a severe car accident that occurred six months ago. He reports frequent intrusive memories of the accident, recurring nightmares that disturb his sleep, and intense anxiety when driving or riding in vehicles. Michael describes heightened startle responses to loud noises and constant hypervigilance, particularly in traffic. He has been avoiding driving and taking longer routes to work to avoid the accident location. Michael rates his distress as 9 out of 10 when confronted with trauma-related triggers. He reports that these symptoms have significantly impacted his work commute and social life. No previous history of mental health conditions, and currently not taking any medications.
Objective
- Appearance:
- Well-groomed, visibly tense
- Behavior:
- Hypervigilant, frequently scanning room
- Mood/Affect:
- Anxious mood, constricted affect
- Speech:
- Clear, occasionally rapid when discussing accident
- Thought Process:
- Organized but preoccupied with trauma
- Cognition:
- Alert and oriented, intact memory
Assessment
Michael presents with symptoms consistent with Post-Traumatic Stress Disorder following a significant traumatic event. His symptoms meet diagnostic criteria including re-experiencing, avoidance, negative alterations in cognition and mood, and heightened arousal and reactivity. The impact on his daily functioning is severe, particularly affecting his ability to travel and maintain normal work routines. His insight into his condition and motivation for treatment are positive prognostic factors. Treatment will focus on trauma-focused therapy, coping skills development, and gradual exposure work.
Plan
-
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT):
- Process traumatic memories safely
- Address trauma-related cognitive distortions
- Develop trauma narrative when appropriate
-
Exposure Therapy:
- Create hierarchy of avoided situations
- Begin gradual exposure exercises
- Practice in-vivo exposure when ready
-
Coping Skills Development:
- Teach grounding techniques
- Practice relaxation exercises
- Implement stress management strategies
-
Sleep Hygiene:
- Establish consistent sleep schedule
- Develop pre-sleep relaxation routine
- Address nightmare frequency
-
Follow-Up:
- Weekly sessions for first three months
- Regular assessment of symptom severity
- Coordinate with primary care physician if needed
ICD-10 Code: F43.10 (Post-traumatic stress disorder)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
4. Obsessive-Compulsive Disorder (OCD)
Description
The patient presents with intrusive thoughts and compulsive behaviors centered around contamination fears and checking rituals, significantly impacting daily functioning.
SOAP Note
Patient Name: Emily Rodriguez
Date of Visit: 09/04/2024
Subjective
Emily Rodriguez presents with worsening OCD symptoms over the past year. She reports persistent intrusive thoughts about contamination and disease, leading to excessive hand washing (20+ times daily, 5+ minutes each time) and cleaning rituals. Emily describes spending approximately 4-5 hours daily on cleaning routines and checking behaviors (repeatedly checking door locks, stove knobs, and light switches). She rates her anxiety as 8/10 when unable to complete rituals. These symptoms have caused her to be consistently late to work and have strained her relationships. Emily reports raw, cracked hands from frequent washing and significant distress about the time lost to compulsions. She has no previous mental health treatment history and is not currently taking any medications.
Objective
- Appearance:
- Well-groomed, visible skin irritation on hands
- Behavior:
- Anxious, frequent use of hand sanitizer
- Mood/Affect:
- Anxious mood, appropriate affect
- Speech:
- Normal rate and tone
- Thought Process:
- Logical but preoccupied with contamination fears
- Cognition:
- Alert and oriented, insight into irrational nature of thoughts
Assessment
Emily presents with symptoms consistent with Obsessive-Compulsive Disorder, characterized by contamination obsessions and cleaning/checking compulsions. Her symptoms cause significant functional impairment in occupational and social domains. The physical manifestation of symptoms (hand irritation) indicates severity requiring immediate intervention. Emily demonstrates good insight into the irrational nature of her thoughts, which is a positive prognostic indicator. Treatment will focus on Exposure and Response Prevention (ERP) therapy, along with cognitive restructuring and stress management techniques.
Plan
-
Exposure and Response Prevention (ERP):
- Develop hierarchy of exposures
- Begin graduated exposure exercises
- Practice response prevention techniques
-
Cognitive Restructuring:
- Challenge OCD-related beliefs
- Develop realistic thought patterns
- Build tolerance for uncertainty
-
Behavioral Modifications:
- Create time-limited cleaning routines
- Implement "one-and-done" checking rule
- Develop alternative coping strategies
-
Self-Care Planning:
- Address hand irritation issues
- Establish healthy boundaries
- Incorporate stress-reduction activities
-
Follow-Up:
- Twice-weekly sessions initially
- Weekly progress monitoring
- Consider psychiatric referral if needed
ICD-10 Code: F42.2 (Obsessive-compulsive disorder)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
5. Bipolar Disorder
Description
The patient presents with a history of alternating episodes of depression and mania, currently experiencing symptoms of hypomania following a recent depressive episode.
SOAP Note
Patient Name: David Thompson
Date of Visit: 09/05/2024
Subjective
David Thompson presents with symptoms of hypomania following a three-month depressive episode that ended two weeks ago. He reports decreased need for sleep (sleeping 4-5 hours nightly), increased energy, rapid speech, racing thoughts, and engaging in multiple new projects simultaneously. David describes spending excessively on unnecessary items and making impulsive business decisions. He acknowledges a pattern of mood episodes over the past five years, with depressive episodes lasting 2-4 months and hypomanic episodes lasting 2-3 weeks. Currently taking lithium 900mg daily but admits to occasional non-compliance. Reports no current suicidal ideation but has history of one suicide attempt during a depressive episode two years ago.
Objective
- Appearance:
- Well-dressed, somewhat disheveled
- Behavior:
- Restless, frequently shifting position
- Mood/Affect:
- Elevated mood, expansive affect
- Speech:
- Pressured, rapid rate
- Thought Process:
- Flight of ideas, tangential
- Cognition:
- Alert but distractible
Assessment
David presents with symptoms consistent with Bipolar I Disorder, currently in a hypomanic episode. His symptoms indicate a need for immediate intervention to prevent progression to full mania. Medication non-compliance appears to be a contributing factor to mood instability. Current symptoms significantly impact his financial decision-making and professional relationships. Risk assessment indicates no immediate safety concerns, but history of suicide attempt warrants close monitoring. Treatment will focus on mood stabilization, medication compliance, and development of a comprehensive wellness plan.
Plan
-
Medication Management:
- Coordinate with psychiatrist regarding compliance
- Implement medication tracking system
- Educate about importance of consistency
-
Mood Monitoring:
- Implement daily mood tracking
- Identify early warning signs
- Develop crisis prevention plan
-
Cognitive Behavioral Therapy:
- Address cognitive distortions
- Develop realistic goal-setting
- Improve impulse control strategies
-
Lifestyle Structure:
- Establish consistent sleep schedule
- Create daily routine
- Set healthy boundaries
-
Follow-Up:
- Schedule twice-weekly sessions
- Coordinate with psychiatrist
- Regular risk assessments
ICD-10 Code: F31.1 (Bipolar disorder, current episode hypomanic)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
6. Schizophrenia
Description
The patient presents with chronic schizophrenia, experiencing positive and negative symptoms, with recent increase in auditory hallucinations despite medication compliance.
SOAP Note
Patient Name: James Wilson
Date of Visit: 09/06/2024
Subjective
James Wilson presents with reports of increased auditory hallucinations over the past two weeks, despite compliance with prescribed antipsychotic medication (risperidone 4mg daily). He describes hearing multiple voices commenting on his actions and occasionally giving commands, though he states he can resist these commands. James reports continued paranoid thoughts about being watched through electronic devices but acknowledges these may not be real. He describes ongoing negative symptoms including social withdrawal, reduced emotional expression, and lack of motivation. Sleep and appetite remain stable. James denies any current suicidal or homicidal ideation. He lives independently but receives weekly support from his sister.
Objective
- Appearance:
- Adequately groomed, appropriate dress
- Behavior:
- Reduced psychomotor activity
- Mood/Affect:
- Neutral mood, flat affect
- Speech:
- Reduced spontaneity, brief responses
- Thought Process:
- Generally organized with some paranoid content
- Cognition:
- Alert, oriented to person/place/time
- Perceptions:
- Active auditory hallucinations
Assessment
James presents with chronic schizophrenia with recent exacerbation of positive symptoms, particularly auditory hallucinations, despite medication compliance. Negative symptoms remain prominent but stable. Current living situation appears appropriate with good family support system. No immediate safety concerns identified. Treatment will focus on coping strategies for hallucinations, reality testing, and negative symptom management while maintaining current level of independence.
Plan
-
Symptom Management:
- Review and enhance coping strategies for hallucinations
- Practice reality testing techniques
- Develop distraction methods
-
Social Skills Training:
- Gradual exposure to social situations
- Practice conversation skills
- Identify community support resources
-
Daily Living Skills:
- Maintain independent living skills
- Establish structured daily routine
- Set achievable personal goals
-
Family Support:
- Coordinate with sister regarding support needs
- Provide family psychoeducation
- Develop crisis plan with family
-
Follow-Up:
- Weekly therapy sessions
- Coordinate with psychiatrist
- Monitor medication effectiveness
ICD-10 Code: F20.9 (Schizophrenia)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
7. Attention-Deficit/Hyperactivity Disorder (ADHD)
Description
The patient presents with adult ADHD symptoms affecting work performance and daily organization, seeking strategies for better symptom management.
SOAP Note
Patient Name: Rachel Foster
Date of Visit: 09/07/2024
Subjective
Rachel Foster presents with ongoing ADHD symptoms that are increasingly impacting her work performance. She reports difficulty maintaining focus during meetings, frequently missing deadlines, and struggling with task prioritization. Rachel describes her workspace as chronically disorganized, often misplacing important documents. She reports starting multiple projects simultaneously but having trouble completing them. Recently received a performance improvement plan at work due to these issues. Currently taking Adderall XR 20mg daily with some benefit but feels additional coping strategies are needed. Sleep is adequate but reports difficulty with morning routine and consistently arriving late to work. No comorbid conditions reported.
Objective
- Appearance:
- Professional attire, fidgeting with phone
- Behavior:
- Frequently shifts position, easily distracted
- Mood/Affect:
- Frustrated mood, full affect
- Speech:
- Rapid, occasionally tangential
- Thought Process:
- Goal-directed but jumps between topics
- Cognition:
- Alert, intact, shows difficulty sustaining attention
Assessment
Rachel presents with symptoms consistent with Adult ADHD, predominantly combined type, with significant impact on occupational functioning. Current medication provides partial symptom relief, but organizational and time management difficulties persist. High level of insight into challenges and strong motivation for improvement are positive prognostic factors. Treatment will focus on developing practical strategies for workplace success, time management, and organization while maintaining medication management through her psychiatrist.
Plan
-
Organizational Skills Development:
- Implement digital calendar system
- Create structured filing system
- Establish priority-setting methods
-
Time Management Strategies:
- Design morning routine
- Practice time-blocking techniques
- Set up reminder systems
-
Workplace Accommodations:
- Identify helpful workplace modifications
- Practice meeting focus strategies
- Develop project tracking system
-
Behavioral Techniques:
- Implement reward system
- Break tasks into manageable steps
- Create environmental modifications
-
Follow-Up:
- Weekly sessions initially
- Coordinate with psychiatrist
- Regular workplace progress review
ICD-10 Code: F90.2 (Attention-deficit hyperactivity disorder, combined type)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
8. Eating Disorders
Description
The patient presents with bulimia nervosa, engaging in binge-eating and purging behaviors, with associated anxiety about body image and weight.
SOAP Note
Patient Name: Lauren Mitchell
Date of Visit: 09/08/2024
Subjective
Lauren Mitchell presents with ongoing bulimic behaviors, reporting 4-5 binge-purge episodes per week, an increase from previous month. She describes feelings of loss of control during binges, followed by self-induced vomiting and excessive exercise to compensate. Lauren reports intense fear of weight gain and persistent dissatisfaction with body image. She acknowledges spending approximately 3-4 hours daily thinking about food, weight, and body shape. Current weight is stable but reports significant fluctuations. Exercise routine has become compulsive (2-3 hours daily). Denies use of laxatives or diuretics. Reports occasional dizziness and fatigue. Previous outpatient treatment two years ago. Currently not taking any medications.
Objective
- Appearance:
- Normal weight, well-groomed
- Behavior:
- Cooperative, shows anxiety when discussing food
- Mood/Affect:
- Anxious mood, constricted affect
- Speech:
- Normal rate and tone
- Thought Process:
- Preoccupied with weight and food
- Physical Observations:
- Calluses on knuckles
- Normal vital signs
Assessment
Lauren presents with symptoms consistent with Bulimia Nervosa, with recent increase in frequency of binge-purge episodes. Physical symptoms suggest active purging behaviors. High level of preoccupation with weight and shape indicates significant body image disturbance. Compulsive exercise patterns raise concern for potential medical complications. Current symptoms significantly impact daily functioning and emotional well-being. Treatment will focus on interrupting binge-purge cycle, addressing body image concerns, and developing healthy coping mechanisms.
Plan
-
Medical Monitoring:
- Regular vital sign checks
- Coordinate with primary care physician
- Monitor for purging complications
-
Nutritional Intervention:
- Implement regular eating schedule
- Develop meal planning strategies
- Address fear foods gradually
-
Cognitive Behavioral Therapy:
- Challenge eating disorder thoughts
- Develop body image acceptance
- Address perfectionist tendencies
-
Behavioral Modifications:
- Implement binge-purge prevention strategies
- Develop healthy exercise guidelines
- Create alternative coping skills
-
Follow-Up:
- Twice-weekly sessions initially
- Consider support group referral
- Regular progress assessment
ICD-10 Code: F50.2 (Bulimia nervosa)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
9. Substance Use Disorders
Description
The patient presents with alcohol use disorder in early remission, seeking continued support for maintaining sobriety and managing triggers.
SOAP Note
Patient Name: Marcus Bennett
Date of Visit: 09/09/2024
Subjective
Marcus Bennett presents for ongoing support in maintaining sobriety from alcohol, currently reporting 45 days of abstinence following completion of intensive outpatient program. He identifies increased cravings in social situations and after work stress. Marcus reports attending AA meetings 3-4 times weekly and has secured a sponsor. He describes ongoing relationship strain with spouse due to past alcohol use but notes improvement in communication. Sleep has improved since achieving sobriety but reports occasional insomnia. Currently taking naltrexone 50mg daily as prescribed. Denies current use of other substances. Reports using newly learned coping skills but still struggles with anxiety in triggering situations.
Objective
- Appearance:
- Well-groomed, casual dress
- Behavior:
- Engaged, maintains good eye contact
- Mood/Affect:
- Cautiously optimistic mood, appropriate affect
- Speech:
- Clear, coherent
- Thought Process:
- Goal-directed, future-oriented
- Cognition:
- Alert, oriented, good insight
Assessment
Marcus presents with Alcohol Use Disorder in early remission, showing good engagement in recovery process. Current stressors include work-related stress and relationship repair. Demonstrates strong motivation for continued sobriety and good utilization of support systems. Risk of relapse is moderate due to early recovery stage but mitigated by active participation in treatment and support groups. Treatment will focus on maintaining sobriety, developing additional coping strategies, and addressing underlying anxiety and relationship issues.
Plan
-
Relapse Prevention:
- Identify and manage triggers
- Enhance coping strategies
- Develop crisis plan
-
Support System Enhancement:
- Continue AA participation
- Strengthen relationship with sponsor
- Build sober social network
-
Relationship Counseling:
- Address trust rebuilding
- Improve communication skills
- Process past alcohol-related conflicts
-
Stress Management:
- Develop healthy stress responses
- Practice mindfulness techniques
- Implement work-life balance
-
Follow-Up:
- Weekly individual sessions
- Coordinate with psychiatrist
- Monitor medication effectiveness
ICD-10 Code: F10.21 (Alcohol dependence, in remission)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)
10. Personality Disorders
Description
The patient presents with borderline personality disorder, experiencing difficulties with emotional regulation, interpersonal relationships, and self-image.
SOAP Note
Patient Name: Sophia Rivera
Date of Visit: 09/10/2024
Subjective
Sophia Rivera presents with ongoing difficulties in emotional regulation and interpersonal relationships. She reports recent relationship conflict leading to impulsive termination of a two-year relationship, followed by intense efforts to reconcile. Describes chronic feelings of emptiness and uncertainty about self-identity. Reports engaging in non-suicidal self-injury (superficial cutting) twice in past week when feeling overwhelmed. Experiences rapid mood shifts multiple times daily, rating emotional intensity as 8/10. Currently taking sertraline 100mg daily and quetiapine 50mg as needed for anxiety. Reports partial compliance with DBT skills practice but acknowledges difficulty implementing skills during crisis moments.
Objective
- Appearance:
- Stylishly dressed, visible old scars on arms
- Behavior:
- Initially guarded, becomes emotionally expressive
- Mood/Affect:
- Labile mood, intense affect
- Speech:
- Rapid at times, normal volume
- Thought Process:
- Circumstantial, focused on relationship issues
- Cognition:
- Alert, oriented, shows dichotomous thinking
Assessment
Sophia presents with symptoms consistent with Borderline Personality Disorder, currently experiencing acute distress related to relationship disruption. Recent increase in self-injurious behavior indicates elevated risk requiring close monitoring. Demonstrates some skill acquisition from DBT but struggles with consistent application. Current symptoms significantly impact interpersonal functioning and emotional stability. Treatment will focus on enhancing emotional regulation skills, reducing self-injurious behaviors, and improving interpersonal effectiveness.
Plan
-
Dialectical Behavior Therapy:
- Review and reinforce DBT skills
- Practice mindfulness techniques
- Enhance emotion regulation strategies
-
Safety Planning:
- Update crisis response plan
- Identify alternative coping methods
- Review suicide risk assessment
-
Interpersonal Effectiveness:
- Practice boundary setting
- Develop communication skills
- Address relationship patterns
-
Identity Development:
- Explore personal values
- Build self-awareness
- Enhance stability of self-image
-
Follow-Up:
- Continue weekly individual therapy
- Encourage DBT group participation
- Coordinate with psychiatrist
ICD-10 Code: F60.3 (Borderline personality disorder)
CPT Code: 90834 (Psychotherapy, 45 minutes with patient)