Below, I’ll break down exactly how to write a psychiatric SOAP note, and I’ll walk through a full psychiatry SOAP note example for one patient so you can see how it looks in real life.
What is a Psychiatric SOAP Note?
A psychiatric SOAP note is a structured clinical document used to record patient encounters in mental health settings. It stands for Subjective, Objective, Assessment, and Plan, four sections that help providers organize information clearly and consistently during psychiatric evaluations, follow-ups, or therapy sessions.
Unlike general medical notes that focus on lab values or physical symptoms, a psychiatric SOAP note captures a patient’s mood, behavior, thoughts, and safety status. It documents what the patient says, how they present, what the clinician observes, and what decisions are made during the session.
SOAP notes in psychiatry are used to:
- Track symptom progression over time
- Monitor medication response and therapy engagement
- Create a paper trail for clinical decisions
- Communicate clearly with other providers
A well-written psych SOAP note ensures continuity of care and protects both the patient and clinician by documenting risk factors and interventions thoroughly. Whether you’re working in outpatient psychiatry, inpatient units, or telehealth, SOAP is the gold standard format across most mental health documentation workflows.
12 Real World Psychiatric SOAP Note Example
Each of these examples shows how a psychiatric SOAP note might look in real-world outpatient mental health practice. The cases are fictional but realistic; useful for clinicians, students, and anyone learning how to document psychiatric evaluations and follow-ups using the SOAP format.
1. Example SOAP Note For Depression – Medication Follow-Up
S:
Patient reports ongoing fatigue and lack of interest. “I’ve been sleeping okay, but I have no energy to do anything.” Mentions skipping social plans due to low motivation. No urgent safety concerns reported.
O:
Appears tired but well-groomed. Affect subdued. Speech slow but coherent. Thought process organized. No unusual behavior or perceptual disturbances.
A:
Depressive symptoms are still present, though no significant worsening. The patient shows partial response to current interventions.
P:
Continue current care plan with slight adjustments. Encourage daily structure, healthy routine, and follow-up support. Reassess in two weeks.
2. Example SOAP Note For Mood Concerns – Passive Low Mood Thoughts
S:
Patient states, “Sometimes I just wish I could sleep and not have to deal with anything.” Denies any intent or plan to act on these thoughts. Reports increased isolation and missing appointments.
O:
Affect appears flat. Eye contact limited. Thought content focused on hopelessness. Behavior calm and cooperative. No acute distress noted.
A:
Low mood with passive distress thoughts. Risk assessed as minimal at this time due to lack of active intent and presence of support system.
P:
Reviewed support plan and coping strategies. Encouraged engagement with therapist. Patient agreed to check in regularly. Follow-up in one week for closer monitoring.
3. Example SOAP Note For Thought Disturbance – Missed Medication
S:
Patient reports difficulty focusing and hearing things that others don’t hear. Admits to not taking prescribed treatment due to feeling “off” with it. No recent stressful events or substance use reported.
O:
Displays distracted behavior and reduced eye contact. Appears to be internally preoccupied. Insight and judgment are limited.
A:
Symptoms suggestive of increased thought disturbance, possibly linked to treatment interruption. Needs closer observation and structured support.
P:
Discussed restarting prescribed care plan under supervision. Provided information on side effect management. Scheduled early follow-up and coordinated with family for extra support.
{{templates}}
4. Example SOAP Note For Bipolar Disorder – Stability Check
S:
Patient reports feeling emotionally balanced. No recent mood shifts or impulsive behavior. States, “Things have been stable for the last few weeks.” No concerns with sleep or work functioning.
O:
Affect full range. Behavior appropriate. Thought process linear. Judgment and insight both intact. No observable symptoms today.
A:
Mood condition remains stable. No indication of current distress or instability.
P:
Continue with the current approach. Schedule routine check-in in four weeks and continue wellness strategies.
5. Example SOAP Note For Anxiety – Moderate Progress
S:
Patient shares ongoing worry, especially in the evenings. “It’s not overwhelming, but I still can’t relax fully.” Sleep improved slightly. Engaged in therapy and using breathing techniques daily.
O:
Mildly tense posture. Speech normal. Appears engaged and open. Thought content focused on everyday concerns. No red flags noted.
A:
Anxiety is improving gradually. Patient appears committed to therapy and self-care strategies.
P:
Continue with therapy plan. Introduce journaling and additional coping exercises. Follow up in three weeks.
6. Example SOAP Note For Post-Trauma – Initial Evaluation
S:
Patient describes difficulty sleeping, frequent intrusive memories, and avoiding certain places or people. Prefers to stay home. No current thoughts of self-harm or unsafe behaviors.
O:
Affect anxious. Alert but easily startled. Avoids eye contact during sensitive discussion. Speech pressured at times. Orientation and memory intact.
A:
Symptoms consistent with post-trauma stress response. No current indication of crisis, but close follow-up is recommended due to intensity of emotional symptoms.
P:
Initiated supportive care plan and referred for trauma-informed therapy. Reviewed daily grounding techniques. Check-in visit scheduled for next week.
These expanded psych SOAP note examples reflect common outpatient scenarios, including mood disorders, anxiety, trauma, and challenges with treatment engagement. Each note keeps language professional, sensitive, and appropriate for diverse clinical contexts — from early intakes to routine maintenance visits. Let me know if you'd like a downloadable version or note templates next.
7. Example SOAP Note For Schizophrenia – Medication Non-Adherence
S:
Patient reports feeling “watched” by neighbors and has stopped taking medication due to suspicion it’s “controlling” their mind. Denies auditory hallucinations today but admits to avoiding going outside. No suicidal or violent ideation reported.
O:
Paranoid thought content evident. Guarded behavior. Poor eye contact. Responds to internal stimuli intermittently. Judgment impaired. Insight minimal.
A:
Symptoms consistent with schizophrenia, with exacerbation likely due to medication non-adherence. Moderate risk due to poor insight and withdrawal behavior.
P:
Initiate supervised medication restart. Refer to case manager for adherence support. Consider long-acting injectable antipsychotic. Weekly check-ins for the next month.
8. Example SOAP Note For OCD – Compulsion Management
S:
Patient reports spending “hours” checking locks and washing hands repeatedly. “I know it’s irrational, but I can’t stop.” Feels frustrated but not hopeless. Denies suicidal ideation.
O:
Alert and oriented. Behavior anxious. Speech rapid. Thought content reveals obsessions with contamination and safety. Judgment fair. Insight intact.
A:
Obsessive-Compulsive Disorder (OCD) with intrusive thoughts and ritualistic behaviors impacting daily function.
P:
Continue CBT focused on exposure and response prevention (ERP). Encourage logging compulsions. Evaluate for SSRI dose adjustment. Weekly CBT sessions.
9. Example SOAP Note For ADHD – Academic Impact
S:
Patient states, “I keep zoning out in class and forget everything later.” Reports difficulty with organization and completing tasks. No mood symptoms. Sleep and appetite are normal.
O:
Fidgety during session. Easily distracted by hallway noise. Answers tangential at times but cooperative. Thought process logical. No signs of anxiety or depression.
A:
ADHD – Predominantly inattentive type, affecting academic performance and attention regulation.
P:
Refer for educational testing. Provide psychoeducation on attention strategies. Trial stimulant medication discussed. Parent and teacher input to be gathered.
10. Example SOAP Note For Substance Use – Early Recovery
S:
Patient recently discharged from rehab. Reports 10 days of sobriety. “Cravings come at night, but I’ve stayed clean.” Attending support groups daily. No suicidal thoughts.
O:
Alert. Well-groomed. Mood neutral. Behavior calm and cooperative. Thought process coherent. No withdrawal symptoms observed.
A:
Early remission from alcohol use disorder. Strong initial motivation but vulnerable to relapse due to recent discharge.
P:
Encourage continued group participation. Provide relapse prevention plan. Schedule addiction counselor follow-up. Urine screen next visit.
11. Example SOAP Note For Eating Disorder – Weight Restoration Phase
S:
Patient states, “I’m eating more but still feel guilty after meals.” Reports restrictive thoughts, occasional body checking, and exercising without telling family. No purging. Denies suicidal ideation.
O:
Low-normal BMI. Appears anxious when discussing food. Affect constricted. Thought process organized. Denies active behaviors during session.
A:
Anorexia Nervosa – in partial recovery. Cognitive distortions persist. Risk elevated due to covert behaviors.
P:
Continue nutritional rehab with therapist collaboration. Initiate CBT-E (Enhanced Cognitive Behavioral Therapy). Schedule family support session. Monitor vitals weekly.
12. Example SOAP Note For PTSD – Flashback Management
S:
Patient describes waking from nightmares and “zoning out” during the day when triggered. “Sometimes I feel like I’m back there.” No self-harm or current danger. Avoids certain sounds and places.
O:
Hypervigilant. Eyes dart frequently. Jumpy when door closes loudly. Thought process intact but pressured speech noted. Affect anxious.
A:
Post-Traumatic Stress Disorder (PTSD) with re-experiencing and hyperarousal symptoms. Avoidance behaviors present.
P:
Begin EMDR or trauma-focused CBT. Teach grounding techniques. Assess for prazosin for nightmares. Weekly follow-ups initially.
{{cta}}
How to Write a Psychiatric SOAP Note: Step-by-Step Guide
Here’s how to write a psychiatry SOAP note for a patient in detail.
Patient Profile
Note: The following patient profile is entirely fictional and created for educational purposes only. It is not based on any real individual or identifiable patient record.
- Name: Carlos V.
- Age: 27
- Gender: Male
- Setting: Outpatient psychiatry follow-up (Visit #4)
- Diagnosis: Bipolar II Disorder, most recent episode depressed
- Medication: Lamotrigine 100mg daily
- Psychiatric History: Diagnosed at 22 after a hypomanic episode. Two prior depressive episodes. History of low mood and passive thoughts of hopelessness in 2022.
- Living Situation: Lives alone in an urban apartment
- Support System: Occasional contact with sister; limited social interaction
- Substance Use: Occasional cannabis use (1–2x/month); no other reported substances
Subjective (S)
Carlos reports that his mood has declined over the past two weeks.
“The mornings are brutal again. I can’t get out of bed until like noon. I’m missing client calls, which makes everything worse.”
He describes low motivation, difficulty with focus, and disrupted sleep — falling asleep around 4 a.m. and waking around midday. Appetite has decreased slightly, but weight remains stable.
Carlos also mentioned having passive thoughts reflecting emotional exhaustion:
“I’m not thinking about doing anything, but if I got hit by a car, I wouldn’t care.”
He acknowledges avoiding social activities and skipping his last therapy session. He continues to take his prescribed medication daily but questions its benefit. Denies any recent high-energy behavior, rapid thoughts, or impulsive actions.
No recent substance use reported.
What This Means
This psychiatric SOAP note example demonstrates how patient self-reports, lifestyle patterns, and emotional tone are recorded clearly and respectfully. In high-quality psych SOAP notes, clinicians should look beyond symptom labels and focus on patterns, functionality, and treatment engagement. Passive expressions of emotional fatigue or hopelessness should always be noted, even when no immediate concern is reported.
Objective (O)
Mental Status Examination (MSE)
- Appearance: Casual, mildly disheveled, appropriate to season; hygiene adequate
- Behavior: Cooperative but withdrawn
- Speech: Normal tone and volume; slowed rate
- Mood: “Low”
- Affect: Constricted, congruent with stated mood
- Thought Process: Linear, logical, and goal-directed
- Thought Content: No unusual beliefs or obsessions reported
- Perception: No hallucinations or perceptual disturbances
- Cognition: Alert and oriented to person, place, and time; fair concentration
- Insight: Fair — recognizes challenges with mood and function
- Judgment: Intact — responds appropriately to hypothetical safety scenarios
Other Observations
- No signs of acute intoxication
- No abnormal movements observed
- Vitals not obtained at this visit
What This Means
This psychiatrist notes example anchors clinical impressions in direct observation. In a soap note psychiatry context, the mental status exam allows clinicians to track changes over time in behavior, affect, thought clarity, and interpersonal presentation. Even without overt crisis indicators, thorough documentation of how the patient presents during the visit is essential for continuity of care.
Assessment (A)
Carlos continues to experience symptoms consistent with a depressive phase of bipolar disorder. He reports difficulty with motivation, disrupted sleep, diminished interest in work and social activities, and passive emotional fatigue.
Despite ongoing medication use, he is unsure whether it’s making a difference. Therapy attendance has been inconsistent, which may be contributing to symptom persistence. Functional impairments include missing work-related responsibilities and reduced engagement with his support network.
Key observations:
- Ongoing low energy, disrupted sleep, reduced drive
- Passive expressions of emotional withdrawal
- Gaps in therapy participation
- Maintaining safety awareness and appropriate judgment
- No signs of mania, perceptual disturbances, or unusual thought patterns
Risk level is assessed as low. Carlos expressed openness to treatment adjustments and agreed to continue check-ins and support planning.
What This Means
A well-written psych SOAP note example doesn’t just list symptoms — it interprets the clinical picture. Here, the assessment links Carlos’s self-report, observed behavior, and functional status into a cohesive summary. It also reinforces that emotional fatigue — even without immediate safety risk — still requires a thoughtful care plan.
Plan (P)
Note: Medication changes and strategies listed here are hypothetical and for educational use only.
Medication:
- Continue lamotrigine 100mg PO daily
- Titrate to 125mg in 7 days if tolerated
- Monitor for side effects or any adverse changes
Therapy:
- Encourage re-engagement with weekly CBT
- Patient to confirm upcoming session with therapist
- Therapist to address avoidance behaviors and daily structure
Safety & Support:
- Discussed internal and external coping strategies
- Reviewed emotional wellness plan
- Provided crisis contact information and local support numbers
- Patient demonstrated understanding and agreed to contact provider if distress increases
- No immediate need for emergency referral or intensive care
Monitoring:
- Follow-up in 2 weeks
- Reassess mood stability, energy, and functional improvements
- Adjust plan based on medication response and therapy adherence
What This Means
This psychiatric SOAP note example demonstrates how a thoughtful, balanced care plan is documented. It reflects Carlos’s current needs, respects his autonomy, and builds in clear checkpoints for evaluating progress. In psych SOAP notes, especially with complex mood conditions, this kind of structured follow-up shows both clinical accountability and patient-centered care.
Common Mistakes to Avoid in Psychiatry SOAP Notes
Even experienced clinicians slip into autopilot with documentation.
But in psychiatry, vague or incomplete notes can miss safety risks, confuse treatment planning, or worse, leave you exposed legally.
Below are some of the most common mistakes I see when reviewing or teaching how to write a psychiatric SOAP note.
These apply whether you're documenting a full psychiatric SOAP note example, a quick med check, or a higher-risk SOAP note for a patient.
- Vague Statements With No Clinical Value
Mistake:
Writing things like “Patient doing well” or “Seems better.”
What to do instead:
Always include observable changes in behavior, mood, or functioning.
Use specific language like,
“Patient reports increased energy and returned to part-time work. Denies SI. Sleep improved to 7 hours/night.”
In any psych SOAP note, your Subjective and Assessment sections should tell a clear story — vague language doesn’t help you, your colleagues, or the patient.
- Skipping the Safety Assessment
Mistake:
Not documenting any risk just because the patient said “I’m fine.”
What to do instead:
Always ask. Always document the response. Even if SI/HI is denied, write it down.
Example:
“Denies SI/HI. No plan or intent. Passive death wishes noted. Agreed to safety plan.”
In any psychiatric notes, especially in cases involving mood disorders or trauma, a missing risk assessment is a red flag. If you’re ever unsure — write it.
- Using Judgmental or Clinical Jargon Without Evidence
Mistake:
Phrases like “Patient is manipulative”, “non-compliant”, or “resistant.”
What to do instead:
Describe behavior neutrally. Stick to what you observed or what the patient reported.
Good: “Patient missed therapy appointment last week. Stated she ‘didn’t feel like going’ due to low energy.”
Avoid: “Patient is non-compliant with therapy.”
A strong psychiatrist notes example will always stay objective. These notes are shared across teams, and loaded language can bias care.
- Leaving Out Objective Mental Status Details
Mistake:
Skipping over nonverbal cues, or leaving the Objective section half-empty.
What to do instead:
Document affect, eye contact, speech patterns, and thought process at minimum.
Even a brief SOAP note psychiatry update should include something like:
“Affect constricted. Speech slow but coherent. Eye contact intermittent. No psychosis noted.”
These details matter when tracking trends — especially in cases of bipolar disorder, or psychosis.
- No Follow-Up Plan or Timeline
Mistake:
Ending with “Follow-up as needed” or “Continue current plan.”
What to do instead:
Be specific. When is the patient coming back? What will you reassess?
Example: “Follow-up in 2 weeks to monitor lamotrigine titration and mood stability.”
A SOAP note example mental health professionals can trust always includes a next step. It signals continuity, accountability, and clinical intention.
How to Write a Psychiatric SOAP Note with AI?
Lindy’s Psychiatry Scribe can help psychiatrists, psych NPs, and therapists spend less time on documentation, without compromising accuracy.
Instead of typing out every psychiatric SOAP note, Lindy lets you write it by:
- Instantly generate detailed HPIs and subjective narratives in your own style
- Chart MSEs, SOAPs, DAPs, referral letters, and even billing codes — in seconds
- Push final notes directly to your EMR
- Customize templates for every patient type — from psychotherapy to counseling
- Reduce documentation time by up to 80% and save 2+ hours a day
- Use Lindy on your phone or laptop, in 13 languages, fully HIPAA/PIPEDA compliant
Whether you're charting after a telehealth call or wrapping up back-to-back sessions, Lindy is the only scribe who adapts to your workflow and gets out of the way.
Start with the Psychiatry Scribe template and leave the clinic when your last patient does.
Frequently Asked Questions
1. How To Write A Patient Note?
To write a patient note, follow a structured clinical format like SOAP: Subjective, Objective, Assessment, and Plan. Start by documenting the patient’s own words and concerns (Subjective), followed by your observations and exam findings (Objective). Then provide your clinical impression (Assessment), and end with your treatment strategy and next steps (Plan).
For example, in a psychiatric SOAP note, you’d include:
- Subjective: Mood, sleep, medication effects
- Objective: Mental status exam (MSE), appearance, behavior
- Assessment: Diagnostic impression, symptom changes, risk level
- Plan: Medications, therapy, safety planning, follow-up
A complete patient note should be clear, clinically focused, and legally sound, whether you're documenting a therapy visit, medication check, or full evaluation.
2. How long should a psychiatry SOAP note be?
A psychiatry SOAP note should be long enough to document clinical relevance but short enough to remain focused. Most outpatient notes fall between 250–500 words, while intakes or complex cases may require more. What matters most is clarity, not length as a good psychiatric SOAP note documents symptoms, risk, and your clinical thinking in a structured format.
3. Do I need to include all MSE domains in every note?
Yes, the Mental Status Exam (MSE) should include all core domains like appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Even in short follow-ups, these should be addressed briefly. A complete MSE is essential for any SOAP note example that mental health providers rely on.
4. What if a patient won’t talk much or gives one-word answers?
Document exactly what happens.
For example:
“Patient provided minimal responses; answers were brief and non-elaborative despite open-ended questioning.”
In psychiatry, the absence of speech or reduced engagement is a clinical observation. It belongs in both the Subjective and Objective sections of your psych SOAP note.
5. What if there’s nothing new to report — how do I keep the note meaningful?
Focus on what stayed the same. Stability is clinical information.
For example:
“Patient continues to deny SI/HI. Mood remains low but unchanged. No new med side effects.”
Even a routine follow-up should show that you assessed mood, safety, and functioning. That’s what makes it a complete psychiatry SOAP note, even when no change occurs.
6. Should I include lab results or vitals in the Objective section for psychiatry?
Yes, if obtained, include them. For example:
“BP 118/76. Weight 174 lbs. No recent labs available.”
While psychiatric notes focus mostly on mental status, basic vitals or relevant labs (e.g., lithium levels, metabolic panels) should still be documented when applicable. If they’re not available, simply note that.
7. When do I switch from a SOAP to a different note format like BIRP or DAP?
Use SOAP notes for med management, evaluations, and general psychiatric visits.
Switch to BIRP (Behavior, Intervention, Response, Plan) or DAP (Data, Assessment, Plan) when documenting therapy-focused sessions or inpatient care.
These formats are better suited for behavioral tracking and therapeutic interventions.
%20(1).png)
%20(1).png)
.png)
.jpg)
.png)
