Psychiatry Patient Notes: 12 SOAP Examples + AI Template

After working with clinicians for years and reviewing their psychiatry patient notes, I broke down the SOAP format for beginners with 12 clear examples. Plus, learn how clinicians can use AI to write psychiatry notes faster.

Disclaimer: This article shares general information and examples related to psychiatry patient notes and documentation practices. It does not provide medical, clinical, or legal advice. Examples are illustrative and may not apply to every setting. Clinicians should rely on their own judgment, training, and applicable guidelines, and consult official sources or qualified professionals when making documentation or care decisions.

What is a psychiatric patient note?

A psychiatric patient note is a clinical document that organizes a patient encounter into the SOAP (Subjective, Objective, Assessment, Plan) format. Here’s what it means:

• Subjective: The patient’s own words, symptoms, and concerns
• Objective: Your observations, plus the mental status exam
• Assessment: Your clinical impression and risk evaluation
• Plan: Treatment steps, safety actions, and follow-up

Psychiatry patient notes need a structure that keeps the session clear, objective, and easy to follow. That’s why most clinicians rely on the SOAP format as it clearly reports what the patient says, what you observe, how you interpret the case, and what happens next.

Why psychiatrists use SOAP notes

Psychiatry SOAP notes are different from medical SOAP notes that track vitals or lab trends. Psychiatry notes rely on language, behavior, thought patterns, and safety cues. They focus on how the patient speaks, how they show up, and how their functioning changes over time.

Clinicians use psychiatric SOAP notes to:

• Document session details in a clear, consistent format
• Track progress across weeks or months
• Communicate with therapists, nurses, and care teams
• Record safety information responsibly
• Support medication management and therapy planning

Psychiatry patient notes must be accurate. A small change in affect, speech, or energy level can matter more than a long list of symptoms. SOAP gives those changes a place to live in the record.

The format also reduces the cognitive load of documentation. You don’t have to reinvent how you write after every session. You follow the same path, then adjust based on the case.

How to write a psychiatric SOAP note: Step-by-step guide

The SOAP format keeps the visit organized so psychiatrists like yourself can capture what the patient shared, what you observed, how you interpreted the session, and what you decided to do next. Here is how each part works:

1. Start with a brief patient context

Add only the details that help you understand the session. Include the visit type, diagnosis, current treatment, and anything that affects the clinical picture. A short snapshot gives structure to the note and helps future clinicians follow the case without searching for older records.

A simple context line could look like this: “Fourth follow-up visit for Bipolar II. Current medication is lamotrigine. Recent decline in energy and motivation.” This opens the note without slowing the reader down.

2. Write the Subjective section

The Subjective section captures the patient’s own words. Include symptoms, mood, behavior changes, sleep patterns, appetite shifts, medication effects, and safety statements. Add direct quotes when they add clarity.

For example, a patient in a low mood might say, “Mornings drain me. I stay in bed until noon and avoid calls.” This type of language shows emotional tone, not just symptoms.

Focus on patterns. Look for changes in routine, motivation, and functioning. If the patient skipped therapy or stopped taking medication, document it. If they mention passive hopelessness, capture it clearly. These statements shape the clinical interpretation later.

3. Document the Objective section

The Objective section captures what you observed. This includes the mental status exam, appearance, behavior, speech, thought process, and cognition. The goal is precision, not interpretation.

A clean Objective note for a depressive visit might read like this: “Appearance casual. Behavior cooperative. Speech slowed. Affect constricted. Thought process logical. No hallucinations reported. Insight fair. Judgment intact.”

Include vitals only if they matter that day. Avoid long descriptions that do not add value. Your observations help track changes across time, so consistency helps.

4. Build the Assessment section

Assessment brings the session together. You interpret what the patient reported and what you observed. Summaries work better than long symptom lists.

For example: “Symptoms align with a depressive episode. Low motivation, reduced engagement, and disrupted sleep continue. Safety risk remains low. No signs of mania or psychosis.”

Connect the behavior and functioning to the diagnosis. Note the level of risk. Describe treatment response. Keep the tone neutral and factual.

5. Create the Plan

The Plan section details your next steps. Include medication decisions, therapy recommendations, follow-up timing, safety instructions, and monitoring plans. Make every line actionable.

A simple Plan might include:

• Continue lamotrigine
• Re-engage with weekly CBT
• Review coping strategies
• Check in after two weeks

List only what you intend to do. Avoid vague instructions like “Continue as before.” Follow-up clarity shows clinical intention and supports continuity of care.

6. Review trends across visits

For every visit the patient schedules, track sleep, energy, engagement, safety, and functioning. Detailed psychiatry patient notes help you see what changed and what stayed the same. If nothing changed, state that clearly. Stability still informs care decisions.

Trends also help you spot early signs of relapse or improvement. A patient who slowly withdraws from work or social life shows a pattern that may matter more than a single symptom reported once.

How to write psychiatry patient notes faster with AI

Handwritten psychiatry patient notes give clinicians complete control over how they document each visit. However, the tradeoff is time. Documentation often stretches into evenings and cuts down session time.

That’s why many clinicians use AI to support the same SOAP workflow they already follow.

AI is faster, more accurate, and helps with structure and organization. Here’s how:

• Subjective: Clinicians can review AI-generated notes based on the conversation and keep what reflects the session accurately.
• Objective: Instead of formatting the mental status exam by hand, clinicians can describe their observations and let AI organize them into a clear MSE for review.
• Assessment: Rather than drafting the impression line by line, clinicians can refine an AI-organized summary of what changed, what stayed the same, and how the visit progressed.
• Plan: Clinicians can reuse templates for common visit types and adjust them as needed.

Lindy offers a Psychiatrist Scribe that helps clinicians structure SOAP notes, format MSEs, reuse templates, and send finalized notes to the EMR without a technical setup. The clinician provides the content, reviews the output, and confirms the final version.

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Common mistakes to avoid while writing psychiatry patient notes

Psychiatry patient notes need clarity. Small documentation issues can shape treatment decisions, create confusion across teams, or leave gaps in the clinical record. These are the mistakes clinicians run into most often and how to avoid them:

1. Writing vague statements

Phrases like “patient doing better” or “seems fine” do not help anyone. They hide what changed. Replace them with concrete details. 

For example: “Patient reports improved energy and has returned to work part-time. Sleep has increased to about seven hours per night.”

2. Skipping the safety check

Every visit needs a clear safety statement. Many clinicians skip it when the patient says they feel okay. That creates risk. Ask about thoughts of self-harm, intent, plan, and protective factors. Document the response. 

A simple line works: “Patient reports no immediate safety concerns and understands when to reach out for support if distress increases.”

3. Using judgmental language

Words like “manipulative,” “non-compliant,” or “resistant” add bias. They do not describe behavior. Focus on what happened. 

For example: “Patient missed therapy last week and reports low energy as the reason.” This keeps the note objective and useful for anyone who reads it later.

4. Leaving the Objective section thin

When the Objective section lacks detail, it becomes harder to understand how the patient’s presentation changes over time. Notes on affect, speech, behavior, and thought process provide that reference point.

For example: “Affect flat. Eye contact limited. Speech slow. Thought process organized.” Short observations still give the full picture.

5. Ending without a clear plan

An unclear plan slows future visits. “Follow up as needed” does not clarify the next steps. A strong plan includes medication decisions, therapy steps, safety instructions, and the timing of the next visit. 

For example: “Follow up in two weeks to review sleep and energy. Continue current medication. Encourage daily structure and therapy engagement.”

12 psychiatric SOAP note examples

I’ve compiled 12 common outpatient scenarios and their psychiatry patient note examples that follow the SOAP format. Here’s how they keep documentation clear and structured:

1. Depression during a medication follow-up

• S: The patient reports low mood, fatigue, and less interest in usual activities. They say, ‘I get through the day, but everything feels heavy.’ No immediate safety concerns.
• O: Appearance clean. Speech slow. Affect subdued. Thought process logical. No hallucinations.
• A: Symptoms suggest a depressive episode with partial response to treatment. Motivation and energy remain low. Safety risk stays low.
• P: Continue medication. Encourage daily structure. Reinforce sleep routine. Schedule a follow-up in two weeks.

Takeaway: Capture mood, energy, functioning, and safety clearly during depressive follow-ups.

2. Low mood with passive hopelessness

• S: The patient says, “Sometimes I want everything to stop, but I would never act on it.” They report isolation and missed appointments.
• O: Affect flat. Eye contact limited. Behavior calm. Thought content focused on helplessness.
• A: Low mood with passive hopelessness. No intent or plan. Social withdrawal continues.
• P: Review coping strategies. Encourage therapy engagement. Increase contact frequency. Follow up in one week.

Takeaway: Passive hopelessness belongs in the note even without active intent.

3. Thought disturbance after missed medication

• S: The patient reports trouble focusing and occasional internal voices. They stopped medication because it felt “off.”
• O: Behavior distracted. Eye contact brief. Thought process concrete. Insight poor.
• A: Worsening thought disturbance linked to medication interruption. Higher need for structured support.
• P: Restart medication. Review side effects. Involve family for adherence support. Schedule an early follow-up.

Takeaway: Link thought changes to medication patterns when relevant.

4. Bipolar disorder during a stability check

• S: The patient reports a stable mood and steady sleep. They deny impulsive behavior.
• O: Affect full. Behavior appropriate. Thought process linear. Judgment intact.
• A: Bipolar disorder remains stable with no signs of depression or hypomania.
• P: Continue current plan. Reinforce wellness routines. Follow up in four weeks.

Takeaway: Stability still needs documentation.

5. Anxiety with moderate improvement

• S: The patient reports persistent worry, especially at night. They say, “I feel tense, but I manage better than before.” Sleep improves slightly.
• O: Posture tense. Speech clear. Affect anxious. Thought content focused on routine stressors.
• A: Anxiety shows gradual improvement. Patient uses coping skills consistently.
• P: Continue therapy. Add journaling and grounding exercises. Follow up in three weeks.

Takeaway: Show progress without overstating improvement.

6. Post-trauma symptoms during an initial evaluation

• S: The patient reports intrusive memories, poor sleep, and avoidance of certain places. They deny suicidal thoughts.
• O: Affect anxious. Startle response strong. Avoids eye contact. Speech pressured at times.
• A: Symptoms align with a post-traumatic stress response. No crisis present, but emotional intensity stays high.
• P: Begin trauma-informed therapy. Review grounding exercises. Schedule a follow-up next week.

Takeaway: Early trauma notes need clear tracking of avoidance, arousal, and safety.

7. Schizophrenia with medication non-adherence

• S: The patient believes neighbors watch them. They stopped medication because it feels “controlling.” They deny command hallucinations.
• O: Thought content paranoid. Behavior guarded. Eye contact poor. Responds to internal stimuli at times. Insight minimal.
• A: Exacerbation of schizophrenia linked to poor adherence. Moderate risk due to limited insight.
• P: Restart medication with support. Refer to the case manager. Consider a long-acting injectable. Arrange weekly check-ins.

Takeaway: Describe paranoia neutrally and document insight clearly.

8. OCD with compulsive behaviors

• S: The patient spends hours checking locks and washing hands. They say, “I know it makes no sense, but I cannot stop.” They deny suicidal thoughts.
• O: Behavior anxious. Speech rapid. Thought content focused on contamination and safety.
• A: OCD with intrusive thoughts and compulsive rituals that impair function.
• P: Continue CBT with exposure and response prevention. Track compulsions. Review medication options. Follow up weekly.

Takeaway: Document both obsessions and compulsions for clarity.

9. ADHD affecting academic performance

• S: The patient says, “I zone out during class and forget everything.” They report trouble organizing tasks.
• O: Behavior fidgety. Easily distracted. Answers drift off topic but stay coherent.
• A: ADHD, predominantly inattentive type, affecting school performance.
• P: Recommend educational testing. Review attention strategies. Discuss stimulant options. Gather feedback from teachers and family.

Takeaway: Highlight functional impact, not just symptoms.

10. Substance use in early recovery

• S: The patient reports ten days of sobriety after rehab. Cravings increase at night. They attend daily support groups.
• O: Appearance neat. Mood neutral. Behavior calm. No withdrawal signs.
• A: Early remission from alcohol use disorder. Motivation is strong, but relapse risk remains elevated.
• P: Reinforce support group attendance. Create a relapse prevention plan. Schedule a counselor follow-up. Order urine screening for the next visit.

Takeaway: Flag vulnerability in early recovery, even with good motivation.

11. Eating disorder during weight restoration

• S: The patient reports increased food intake but guilt after meals. They monitor their body often and exercise secretly. They deny purging or suicidal thoughts.
• O: BMI low-normal. Affect constricted. Anxious behavior during food discussion. Thought process organized.
• A: Anorexia nervosa in partial recovery. Cognitive distortions remain. Risk increases due to secret exercise.
• P: Continue nutritional rehab. Begin CBT-E. Involve family in treatment. Monitor vitals weekly.

Takeaway: Document covert behaviors clearly.

12. PTSD with flashback episodes

• S: The patient reports nightmares and daytime flashbacks. They say, “Sometimes it feels like I am back in it.” They avoid loud sounds and certain locations.
• O: Behavior hypervigilant. Eyes dart around the room. Speech pressured. Affect anxious.
• A: PTSD with re-experiencing, avoidance, and hyperarousal symptoms.
• P: Start trauma-focused therapy or EMDR. Teach grounding skills. Review medication options for nightmares. Follow up weekly.

Takeaway: Track avoidance triggers and re-experiencing symptoms in plain language.

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Try Lindy to write psychiatry patient notes

Lindy’s Psychiatry Scribe can help psychiatrists, clinicians, and therapists spend less time on psychiatry patient notes, without compromising accuracy. You also create custom AI agents for your medical workflows.

Here’s how Lindy helps you write psychiatric SOAP notes:

• Instantly generate detailed HPIs (History of Present Illness) and subjective narratives in your own style
• Chart MSEs, SOAPs, DAPs (Data, Assessment, Plan), referral letters, and even billing codes in seconds
• Integrate 4,000+ tools, including your EMR, and sync your notes automatically
• Ready-to-use, customizable templates for every patient type, from psychotherapy to counseling
• Use Lindy on your phone or laptop, in 30+ languages 
• SOC 2, HIPAA, and PIPEDA compliance for sensitive healthcare data

Lindy offers a free plan with 40 monthly tasks, while the paid plans start from $49.99/month. Try it for free.

Frequently asked questions

How do you write a patient note?

You write a patient note by following a structured format that keeps the visit clear and easy to interpret. Most clinicians use the SOAP format (Subjective, Objective, Assessment, Plan). 

How long should psychiatry SOAP notes be?

Psychiatry SOAP notes usually range from 250 to 500 words for standard outpatient visits. Intake evaluations or complex cases may require more. 

Do you need to include all MSE domains in every note?

Yes, you need to include all mental status exam domains in every psychiatry patient note. These include appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. 

What should you do when a patient gives one-word answers?

You document the behavior exactly as it occurs. Write that the patient gives brief or minimal responses even after open-ended questions. This information belongs in the Subjective and Objective sections because limited engagement holds clinical value.

How do you write a meaningful note when nothing changes?

When nothing changes, you write a meaningful note by focusing on stability. Document that symptoms, functioning, and safety remain the same. 

For example: “Mood stays low but unchanged. Denies suicidal or homicidal thoughts. No new medication effects.” Stability still helps guide treatment.

Should you include vitals or labs in psychiatry notes?

Yes, you should include vitals or lab results when you collect them. For example, list weight, blood pressure, or relevant labs such as lithium levels. If you did not collect these, you can state that directly.

When should you use SOAP instead of BIRP or DAP?

Use SOAP for medication management visits, psychiatric evaluations, and general outpatient sessions. Use BIRP (Behavior, Intervention, Response, Plan) or DAP (Data, Assessment, Plan) for therapy-focused visits or inpatient behavioral tracking.