Sample SOAP Note for Adult Outpatient Psychiatry
A 20-minute medication follow-up for a client on escitalopram. Note how the assessment separates symptom change from the plan, and how the risk screen is documented even when negative.
Fictional composite for training and comparison. Not a real client record and not clinical advice.
Write mineSubjective
- Client presented for a 20-minute medication follow-up, reporting partial improvement in baseline anxiety since the last visit. - Described two panic-free weeks, the longest stretch since March; still describes anticipatory worry before work meetings. - Reports initial nausea for the first ten days on the current dose, now resolved. - Sleep improved to 6.5–7 hours per night; denies early waking. - Denies suicidal ideation, homicidal ideation, and self-harm. Denies alcohol or recreational substance use since last visit.
Objective
- Alert and oriented, casually dressed, good hygiene. Speech normal in rate and volume. - Mood described as "okay, better than before". Affect congruent, mildly restricted. - Thought process linear and goal-directed; no delusional content elicited. No perceptual disturbance. - Insight and judgement intact. No psychomotor agitation or retardation. - Blood pressure 118/76, heart rate 72. Weight stable versus last visit.
Assessment
- Generalized anxiety disorder, continuing, with reduced frequency of panic symptoms on current pharmacotherapy. - Tolerating escitalopram 10 mg without residual side effects. - Sleep and appetite have normalised; functional impairment limited to meeting-related anticipatory anxiety. - Risk: low. No current ideation, plan, or intent; protective factors include engagement in treatment and stable housing.
Plan
- Continue escitalopram 10 mg daily; no dose change at this visit given the trajectory. - Discussed that a dose increase is an option if meeting-related anxiety persists at the next visit. - Continue weekly CBT with the current therapist; coordinated to focus on pre-meeting worry. - Labs ordered: CMP and TSH, results to be reviewed at follow-up. - Return in 4 weeks. Instructed to contact the clinic sooner for worsening mood or any safety concern.
What belongs in each section of a psychotherapy SOAP note
Subjective
Stay in the client's voice. Report what they said about symptoms, side effects, sleep, and function — and always document a risk screen explicitly, including the negatives. "Denies SI/HI" is not filler; it is the line an auditor looks for first.
Objective
This is what you observed, not what you concluded. Mental status elements, vitals, and appearance belong here. Keep interpretation out — "mildly restricted affect" is observation; "depressed" is a conclusion that belongs in Assessment.
Assessment
Carry the diagnosis forward and state the clinical reasoning. Note change since last visit, tolerability, and functional impairment. Risk gets its own sentence with severity and protective factors.
Plan
Every plan line should be actionable and specific: medication and dose, therapy coordination, orders with a named review point, and a return interval with return precautions. Vague plans ("continue current treatment") are the most common audit finding.
Generate this structure from your own notes
The generator takes the same four headings and fills them with your session content — redacted in your browser, editable before you sign, exportable to Word.
Open the generatorCommon questions
How long should a psychiatric SOAP note be?+
A medication follow-up typically runs 150–300 words. Long enough to justify the billing code and document risk, short enough that it takes five minutes to write.
Do I need to document a risk screen at every visit?+
In most jurisdictions and payer policies, yes — including negative findings. A note that is silent on suicidality is treated as not having assessed it.
More sample notes