How to Approach Writing Your SOAP Note

1. Informed Consent

• Always start with documentation that verbal/written consent for psychiatric evaluation and treatment was obtained.

• Mention capacity assessment (i.e., patient oriented, able to understand risks/benefits).

2. Subjective

• Verify Patient Information: Name, DOB, demographics, identifiers.

• Chief Complaint (CC): Patient’s own words in quotes.

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

• Psychiatric Symptom Review: Mood, anxiety, psychosis, eating, substance use, sleep, energy, concentration.

• Safety: SI/HI/AV (Suicidal, Homicidal, Auditory/Visual hallucinations).

• Allergies, Medications, Past Medical/Psych Hx, Family Hx, Trauma Hx, Substance Use, Social Hx.

• Review of Systems (ROS): You can summarize (“ROS non-contributory” unless specific symptoms noted).

3. Objective

• Vitals (if available).

• Labs (tox screen, HCG, CBC, etc. if applicable).

• Mental Status Exam (MSE):

  • Appearance, behavior, speech, mood/affect, thought process/content, perception, cognition, insight, judgment.

• Screening Tools (PHQ-9, GAD-7, C-SSRS, etc).

4. Assessment

• DSM-5 Diagnoses (with ICD-10 codes).

• Differentials: list at least 2–3 and explain why they are more/less likely.

• Clinical Summary/Case Formulation: integrate subjective + objective data into a concise statement (risk factors, protective factors, symptom pattern).

5. Plan

• Pharmacological Plan: Meds (name, dose, route, frequency, rationale).

• Non-Pharmacological Plan: Psychotherapy (CBT, DBT, supportive), psychoeducation, support groups.

• Lifestyle Interventions: Sleep hygiene, exercise, nutrition.

• Referrals: Endocrinology, social work, substance abuse counseling, etc.

• Safety Planning: Suicide prevention, crisis resources.

• Follow-up: Specific time frame (2 weeks, 1 month).

• Counseling/Education: Medication adherence, warning signs, when to seek emergency care.

• Billing/Time Documentation: Time spent, CPT codes if required. APA

 Example (Shortened Version)

Here’s a sample excerpt (so you can see how it looks filled in):

CC: “I can’t stop worrying and I can’t sleep.”
HPI: 28-year-old female with 3-month history of excessive worry, restlessness, poor sleep, muscle tension. Symptoms worsened over past 2 weeks after job loss. Denies SI/HI.
MSE: Neatly dressed, cooperative, anxious mood, affect congruent, speech normal, thought process linear, denies AVH. Cognition intact, insight/judgment fair.
Assessment:

• Generalized Anxiety Disorder (F41.1)

• R/O Major Depressive Disorder (F32.9)
  Plan:

• Start Sertraline 25mg PO daily x1 week → increase to 50mg PO daily.

• Refer to CBT.

• Sleep hygiene education.

• Follow up in 2 weeks.

• Safety: Denies SI, given crisis hotline number.