SOAP Note Template (Psychiatry)
Published: 10/22/2025
About this template:
This psychiatric SOAP note template provides structure for documenting mental health evaluations and treatment sessions. It includes sections for mental status examination, risk assessment, medication effects, and therapeutic interventions. The template supports comprehensive documentation of diagnostic impressions, treatment response, and care coordination, ensuring thorough records for both outpatient and inpatient psychiatric care.
Preview template
Subjective: 32-year-old female with major depressive disorder, currently on sertraline 100mg daily for 6 weeks. Reports improved mood and energy compared to last visit. Sleep has normalized, appetite improved. Denies current suicidal ideation but endorses occasional passive death wishes. Still experiencing difficulty concentrating at work. Anxiety symptoms have decreased. PHQ-9 score today is 11 (down from 19 at baseline).
Objective: Patient appears well-groomed with appropriate hygiene. Mood described as "better" with congruent affect, range improved from previous flat affect. Speech normal rate and volume. Thought process linear and goal-directed. No evidence of psychosis. Denies suicidal or homicidal ideation with no plan or intent. Insight and judgment fair.
Assessment and Plan:
- Major depressive disorder, moderate, improving with current treatment
- Continue sertraline 100mg daily, therapeutic response noted
- Consider adding cognitive behavioral therapy to address residual concentration difficulties and negative thought patterns
- Safety assessment: Low acute risk, patient has support system and coping strategies in place
Patient Education:
- Discussed continued medication adherence and expected timeline for full symptom resolution
- Reviewed importance of sleep hygiene, regular exercise, and social engagement
- Provided crisis resources and encouraged patient to contact office if symptoms worsen
Follow-up in 6 weeks to assess continued progress, sooner if concerns develop.
