SOAP Note Examples
SOAP Note Example for Depression Therapy
Documenting depression therapy sessions requires careful attention to mood changes, functional impairment, and safety considerations. Below is a detailed SOAP note example for a depression therapy session with a reusable template.
Subjective
Client reports persistent low mood for the past four weeks. Describes difficulty getting out of bed most mornings and reduced motivation for activities previously enjoyed, including exercise and socializing. Reports appetite decrease with unintentional weight loss of approximately five pounds. Denies suicidal ideation or self-harm urges. States that prescribed medication was taken consistently this month.
Objective
Client presented with flat affect and psychomotor slowing. Speech was soft and monotone. Eye contact was limited but improved during the session. Appearance was casual but groomed. Client engaged in session content but required more prompting than in previous sessions. No acute safety concerns identified.
Assessment
Presentation consistent with moderate major depressive disorder. Symptoms have worsened since last session, with increased anhedonia and appetite changes. Medication adherence is maintained but current dosage may be insufficient. Client continues to attend sessions and maintain basic self-care, suggesting retained functional capacity despite symptom increase.
Plan
Continue weekly therapy sessions with focus on behavioral activation. Introduce activity scheduling to address anhedonia. Assign mood tracking journal between sessions. Coordinate with prescribing physician regarding potential medication adjustment. Conduct PHQ-9 at next session to quantify symptom severity. Review safety plan and update emergency contacts.
Documenting Depression in Therapy Notes
Depression documentation should capture changes in mood, energy, sleep, appetite, concentration, and interest in activities. Track these symptoms consistently across sessions to monitor treatment response.
Safety assessment is particularly important in depression documentation. Record whether suicidal ideation, self-harm, or hopelessness were assessed and what the client reported. Even when denied, documenting that the assessment was conducted is important for clinical records.
Tracking Treatment Progress
Use standardized measures like the PHQ-9 alongside SOAP documentation to quantify symptom changes. Note the client's response to specific interventions, such as behavioral activation or cognitive restructuring, so treatment adjustments can be supported by documented evidence.
Record medication information including adherence, side effects, and coordination with prescribers. This supports integrated care and helps other providers understand the full treatment picture.
Subjective: [Client's reported symptoms, feelings, and concerns] Objective: [Therapist observations, behavior, appearance, affect] Assessment: [Clinical interpretation and diagnostic impressions] Plan: [Treatment plan, interventions, goals for next session]
Frequently Asked Questions
What should therapists include in depression SOAP notes?
Depression SOAP notes should include the client's reported mood, energy level, sleep and appetite changes, functional impairment, safety assessment results, clinical observations of affect and behavior, diagnostic impressions, and the treatment plan including specific interventions.
How often should depression therapy sessions be documented?
Every therapy session should be documented with a SOAP note. For depression treatment, consistent documentation is especially important for tracking symptom changes, medication coordination, and demonstrating treatment necessity for insurance purposes.
Can AI help write depression therapy notes?
Yes, AI tools can help organize raw session notes into structured SOAP format. LeafNote generates SOAP notes from unstructured therapy notes while scrubbing sensitive identifiers before processing, helping therapists save time on documentation.
Related Resources
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