SOAP Note Template (Mental Health Focus)

S – Subjective

• Identifying Data: Age, gender, ethnicity, living situation.

• Chief Complaint (CC): Patient’s own words (e.g., “I’ve been feeling anxious and can’t sleep”).

• History of Present Illness (HPI): Use OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating/Relieving factors, Treatments tried, Severity).

• Past Psychiatric History: Previous diagnoses, hospitalizations, treatments, therapy history.

• Medical History: Chronic conditions, medications, allergies.

• Family History: Mental illness, substance use, suicide, or major medical conditions.

• Social History: Occupation, relationships, substance use, trauma history, living conditions.

• 

  Review of Systems (ROS): Focus on psychiatric symptoms (mood, anxiety, psychosis, cognition, sleep, appetite, concentration, energy), but include relevant physical symptoms.

O – Objective

• Mental Status Exam (MSE):

  • Appearance

  • Behavior

  • Speech

  • Mood and Affect

  • Thought Process & Content

  • Perceptions (hallucinations/delusions)

  • Cognition (orientation, attention, memory)

  • Insight & Judgment

• Vitals/Physical Exam Findings (if available): BP, HR, weight, relevant neuro findings.

• Screening tools (e.g., PHQ-9, GAD-7, C-SSRS if suicidal ideation).

A – Assessment

• Primary Psychiatric Diagnoses (DSM-5-TR criteria used).

• Differential Diagnoses (explain rationale for inclusion/exclusion).

• Comorbid Conditions (mental health or medical).

• Case Formulation: Summarize patient presentation, risks, protective factors.

P – Plan

• Pharmacological: Medications, dosage, rationale, monitoring.

• Psychotherapy: Type (CBT, DBT, supportive therapy, family therapy).

• Psychoeducation: For patient/family (illness, coping skills, lifestyle modifications).

• Referrals: Psychiatry, primary care, social work, support groups.

• Labs/Diagnostics: e.g., thyroid panel, urine tox, CBC if starting meds.

• Safety Plan: Suicide risk management, crisis numbers.

• Follow-up: Timeline for review (e.g., 2 weeks), adjustments if worsening.

• Patient-Centered Considerations: Incorporate patient preferences, cultural/spiritual beliefs. APA

Grading Rubric Focus

• Clear integration of subjective + objective findings → diagnoses.

• Evidence-based care plan (cite guidelines, e.g., APA, NICE, or DSM-5-TR).

• Patient-centered approach (consider social determinants, culture, family).

• Critical thinking: Show reasoning in assessment and treatment decisions.

• Professional documentation style: concise, clinically appropriate, and HIPAA-compliant.

By the end of the term, your SOAP notes should demonstrate:

• Mastery of psychiatric interviewing/documentation.

• Application of evidence-based guidelines in diagnosis/treatment.

• Consideration of complexity (co-morbidity, psychosocial factors).

• Safe, ethical, patient-centered NP-level care.