SOAP Notes For Mental Health

SOAP notes are an essential mental health feature to healthcare business practices in how they go about clinical documentation management. As a form of progress notes, SOAP outlines patient symptoms and treatment plans and notes every point of communication between the practitioner and their client. They offer a variety of benefits, including:

• Being easy to understand - Their clear format allows for a concise summary of valuable insights concerning patient healthcare information.
• Providing subjective and objective perspectives - This allows for the client's voice to be heard, as well as presenting factual evidence to corroborate data and information that is conveyed. It is a process that encompasses a linear pathway from observations to treatment. 
• Easy to interpret - Using professional language and following a universal guide allows SOAP notes to be versatile in the healthcare sector. They can be understood by a range of healthcare professionals, regardless of their specialty backgrounds.‍
• Supports accountability - Despite SOAP notes being a legal requirement, they allow healthcare businesses to be held responsible for any medical health information. They also allow for them to be compliant in the case of any regulatory, policy, or law issue.

For SOAP mental health progress notes, four main components should be included to ensure your messages are practical for your patients. These include:

• Subjective (S) - This focuses on the client's feelings and experience of their symptoms and often uses quotes as primary evidence for support. For example, third-party excerpts may be used by other close or regular contacts to affirm what is being said. 
• Objective (O) - This includes relevant factual data to support client findings of symptoms. Examples of evidence may include medical records, x-rays, examinations and testing, laboratory data, and vital signs. 
• Assessment (A) - This is a combination of subjective and objective observations and notes the client's progress in regards to their mental health. For instance, this discusses the current diagnosis, improvements, and what the patient could benefit from receiving. ‍
• Plan (P) - Includes the direct course of action and involves targeting the client's specific goals to alleviate their mental health symptoms. For example, this could include breathing techniques for anxiety patients, being forwarded to a psychiatrist for additional medication, etc.

SOAP notes for counseling can look different for each counseling practice. However, practical mental health SOAP notes should still adhere to the general guidelines as discussed. An example of a SOAP note for anxiety has been provided here for your benefit:

Subjective

Bob has been making improvements in regards to his anxiety, stating, "I do feel anxious throughout the day, but it's nowhere near as frequent as it used to be." He says, "I don't feel restless that often, and if I do, I usually just go for my run routine as you suggested, and I feel much better." He says his appetite is "slowly coming back."

Objective

Bob still has anxiety symptoms, such as a loss of appetite and racing thoughts with restlessness. However, they are not as noticeable as before, and Bob demonstrates some regulating behaviors, which is an improvement. 

Assessment

Bob still has anxiety. However, he is making improvements, with symptoms decreasing in nature. They are becoming less prominent in his day-to-day life, but treatment is still needed to solidify his progress.

Plan

As usual, Bob will see me next week, and we have worked further on his regulating techniques to combat ruminating. He will continue to implement what we have worked through, and if symptoms stagnate within the next two weeks, we will reassess his treatment.

In addition to including the main four components of a SOAP note, there are other valuable tips you should incorporate to write solid SOAP notes for mental health. These include:

• Write professionally - Avoiding slang, abbreviations, and colloquialisms make your writing easier to understand by other healthcare professionals who review your notes. It also conveys the patient's experience of mental health with greater clarity. 
• Stay neutral - Refrain from injecting your judgments, assumptions, bias, and interpretations of information, notably in the subjective and objective sections, where you convey the client experience with quotes and relaying relevant medical data. Otherwise, this could lead to misinformation and ineffective treatment plans. 
• Quality over quantity - It is best to write concise notes that get across points quickly and effectively. This way, mental healthcare professionals can gain a clearer picture of the patient and find a way to treat them best.
• Distinguish symptoms and signs should be outlined in the subjective section, and signs of symptoms should be outlined in the objective section. 
• Timing is everything - Write notes shortly after you have seen the patient, so you remember, but not too long in the case you may forget details. 
  

Writing SOAP Notes: Examples + Templates

To guide you along this process, we have also included a sample mental health SOAP note that can be used as a template for your healthcare business practice. This also concerns an individual with anxiety:

Subjective

Tessa is facing significant symptoms of anxiety with difficulty in breathing, "I often have to control my breathing myself since I become so hyper-aware that I have to breathe. It doesn't work, so I end up taking shorter and shorter breaths until I'm practically hyperventilating." She notes, "It also makes me sweat a lot."

Objective

Tessa has moderate to severe anxiety symptoms, with rapid breaths, inability to control anxious thoughts, and sweating. She presented a trembling appearance, and her heart rate confirmed that she presents an above-average rate even resting. She has had no history of anxiety, nor any family history. 

Assessment

Tessa presents concerning symptoms of anxiety, and treatment is necessary to alleviate these symptoms. This is in addition to teaching her techniques to learn to cope, control breathing, and reduce her heightened state. 

Plan

Tessa will continue to see me next week, and she will do so for several sessions agreed upon following next week. I have provided her with some coping strategies to regulate her breathing, and if symptoms persist next week or worsen, we will consider medication to combat her anxiety. 

How do you write mental health progress notes?

Mental health progress notes can be written differently depending on the practitioner's needs and what works best for their business practice. However, as outlined, the best structure for progress notes is the SOAP method, as it covers all critical bases. This could include:

• Subjective - Based on client experience: Jane has been feeling depressed, stating, "I barely have any motivation to get out of bed most days, and I just feel sad for no reason."
• Objective - According to her sleeping tracker, this is based on medical data to show signs of symptoms: Jane has been sleeping more than usual. She has been feeling signs of depression with a loss of motivation and persistent low mood. 
• Assessment - Synthesis of the previous two observations to note progress: Jane indicates that she suffers from depression and is not making any progress with her current sessions. She would benefit from further treatment.
• Plan - Course of action to target specific health goals: Jane will see me next week, and we have worked on techniques to increase productivity. If symptoms do not improve within two weeks, she will be referred to a psychologist for further evaluation. 
  

Final thoughts

SOAP notes for mental health are an excellent way to document patient information clearly and concisely. It enables you to reduce administration time while allowing for a professional way to trace valuable medical information for current and future review. It also provides for other healthcare professionals and healthcare teams to quickly understand the overview of a patient's mental health situation. It paints an accurate picture of their mental health position. 

Many platforms, such as Carepatron, enable you to perfect the SOAP note structure by providing templates and examples free for you to use. This way, you can seamlessly transition to the most effective progress note structure within the healthcare business workspace. This process doesn't have to be a difficult one, and in no time, you can meet your clients' needs with ready-made data. Whatever your decision, meeting the healthcare goals of your patient is of utmost importance, and SOAP notes are the easiest way to guide you to this achievement.

Further reading:

• SOAP notes template in counseling
• SOAP Note Tips