SOAP Note Example for Mental Health: Guide for Students & Interns
Writing a SOAP note for mental health can be challenging for students and interns, especially when dealing with complex psychiatric conditions. This guide offers a real-world example of a mental health SOAP note and breaks down each section to help learners understand how to document mental health assessments clearly and professionally.
In the Subjective section, mental health SOAP notes focus on the patient’s self-reported symptoms, emotional state, and history of psychological issues. This may include mood changes, anxiety levels, hallucinations, or thoughts of self-harm, captured in the patient’s own words.
The Objective section includes observable behaviors and clinical findings, such as the patient’s appearance, speech pattern, body language, and results from standardized psychiatric evaluations. Objective data gives insight into the patient’s mental status from a clinician’s perspective.
The Assessment part involves synthesizing subjective and objective data to provide a diagnosis or mental health impression. For example, a diagnosis like generalized anxiety disorder or bipolar disorder might be documented here, with supporting evidence.
In the Plan section, students are expected to document treatment strategies, therapy referrals, medication adjustments, or monitoring plans. This could include weekly therapy sessions, psychiatric evaluations, or safety plans for patients in crisis.
This blog is designed for mental health students and psychiatric nurse interns who need guidance on structuring effective SOAP notes. The included example is practical, concise, and highlights best practices in psychiatric documentation. With this knowledge, you’ll be better equipped to handle mental health charting confidently and accurately in your clinical setting.
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