Structure and Content of a Psychiatric SOAP Note
A psychiatric SOAP note should follow the standardized format of Subjective, Objective, Assessment, and Plan sections, with comprehensive documentation of mental status examination findings, psychiatric symptoms, and treatment planning to ensure proper patient care and clinical decision-making. 1
Subjective Section
The Subjective section should include:
- Chief complaint and reason for presentation 1
- Patient's goals and preferences for treatment 1
- Psychiatric review of systems, including:
- Anxiety symptoms and panic attacks
- Sleep abnormalities
- Impulsivity assessment 1
- Psychiatric history:
- Past and current psychiatric diagnoses
- Prior psychotic or aggressive ideas
- Prior aggressive behaviors
- Prior suicidal ideas, plans, and attempts (including context, method, damage, lethality, intent)
- Prior intentional self-injury without suicidal intent 1
- Psychiatric treatment history:
- History of psychiatric hospitalizations and emergency visits
- Past psychiatric treatments (type, duration, doses)
- Response to past treatments
- Adherence to past and current treatments 1
- Substance use history:
- Tobacco, alcohol, and other substances
- Prescription or over-the-counter medication misuse 1
- Medical history:
- Allergies and drug sensitivities
- Current medications and side effects
- Primary care relationship
- Past/current medical illnesses and hospitalizations
- Relevant treatments, surgeries, procedures
- Neurological/neurocognitive disorders
- Physical trauma, including head injuries
- Sexual and reproductive history 1
- Family history:
- History of suicidal behaviors in biological relatives (if patient reports suicidal ideas)
- History of violent behaviors in biological relatives (if patient reports aggressive ideas) 1
- Personal and social history:
- Psychosocial stressors (financial, housing, legal, occupational, interpersonal)
- Trauma history
- Exposure to violence or aggressive behavior
- Legal/disciplinary consequences of past aggressive behaviors
- Cultural factors related to social environment
- Need for interpreter 1
Objective Section
The Objective section should include:
- Mental status examination with all nine core domains:
- Appearance
- Behavior
- Speech
- Mood and affect
- Thought process (tangential, circumstantial, loose associations)
- Thought content (delusions, obsessions, suicidal/homicidal ideation)
- Perceptual disturbances
- Cognition
- Insight and judgment 2
- Physical examination findings:
- Height, weight, and BMI
- Vital signs
- Skin examination (including stigmata of trauma, self-injury, or drug use) 1
- Quantitative measures to identify and determine severity of symptoms 1
- Results of any diagnostic tests or assessments
Assessment Section
The Assessment section should include:
- Synthesis of information from Subjective and Objective sections 3
- Current psychiatric diagnoses or differential diagnoses 1
- Assessment of risk:
- Suicide risk assessment
- Violence risk assessment
- Self-harm risk assessment 1
- Assessment of functional impairments 1
- Assessment of hopelessness when suicidal ideation is present 2
- Assessment of treatment needs and priorities
Plan Section
The Plan section should include:
- Comprehensive, person-centered treatment plan including:
- Evidence-based pharmacological interventions
- Evidence-based non-pharmacological interventions 1
- Diagnostic workup plans 4
- Treatment plans 4
- Safety planning
- Follow-up arrangements 5
- Coordination with other healthcare providers
- Patient education
- Documentation of patient's intended course of action if symptoms worsen 2
Documentation Best Practices
- Always sign and date the note 4
- Use the SOAP format consistently to ensure comprehensive evaluation 1
- Document specific observations rather than vague generalizations 2
- Include direct quotes from the patient when relevant
- Document specific thought content (e.g., "paranoid delusions about government surveillance") 2
- Consider cultural factors that may influence presentation and interpretation 1, 2
- Ensure accuracy in all sections of documentation 4
Common Pitfalls to Avoid
- Omitting signature (occurred in 36.8% of student notes in one study) 4
- Documenting physical examination findings under Subjective rather than Objective section 4
- Providing incomplete risk assessments
- Using vague language instead of specific observations
- Failing to document follow-up plans
- Neglecting to assess for hopelessness when suicidal ideation is present 2
- Overlooking cultural factors that may influence symptom presentation and interpretation
By following this structured approach to psychiatric SOAP note documentation, clinicians can ensure comprehensive evaluation, accurate diagnosis, and appropriate treatment planning for patients with psychiatric conditions.