Writing Psychiatric SOAP Notes in NURS-6630N: Realistic Examples and Formatting

In NURS-6630N: Advanced Psychiatric Nursing, writing SOAP notes is an essential skill for Nurse Practitioners (NPs). SOAP notes (Subjective, Objective, Assessment, Plan) are a structured method for documenting patient encounters in psychiatric settings. These notes provide clear, concise, and organized information that ensures effective communication among healthcare professionals and supports continuity of care. In this article, we'll cover how to write psychiatric SOAP notes, provide realistic examples, and explain the formatting you can use to stay consistent in your practice.

What is a SOAP Note?

A SOAP note is a widely-used format for documenting patient information in a systematic and organized manner. Each section of the SOAP note provides important information that is relevant to the patient's care.

  1. S - Subjective: This section includes the patient’s own words and description of their symptoms, thoughts, feelings, and concerns. It captures the patient’s perspective and is usually obtained through a conversation or interview.

  2. O - Objective: This part includes observable, measurable data, such as vital signs, physical exam findings, and observed behaviors. This may also include results from any diagnostic tests.

  3. A - Assessment: Here, you document your clinical judgment and analysis of the patient’s condition. It includes your diagnosis or working diagnosis and reflects on how the subjective and objective findings tie together.

  4. P - Plan: This section outlines the treatment plan, including interventions, referrals, medications, and follow-up care. It also includes patient education and any instructions for the next visit.

General Formatting Tips

  • Be concise: SOAP notes should be clear, concise, and easy to read. Use bullet points when appropriate to break down information.

  • Use direct quotes: In the subjective section, when recording the patient’s statements, try to use their exact words as much as possible.

  • Professional tone: Maintain a professional, neutral, and objective tone in all sections. Avoid using judgmental language or assumptions.

  • Avoid abbreviations: While some abbreviations are common in clinical practice, be mindful of those that may be unclear to others or that could lead to errors.

  • Confidentiality: Always ensure that the patient’s privacy is respected when writing SOAP notes.

Example 1: Major Depressive Disorder (MDD)

S - Subjective:

  • Chief Complaint: "I've been feeling really down and tired for the last few weeks. I just can't seem to get out of bed."

  • History: The patient is a 32-year-old female who reports a 4-week history of persistent low mood, loss of interest in activities she once enjoyed, significant fatigue, and sleep disturbances. She denies any recent life stressors, but reports feeling hopeless about her future. She also reports weight loss and difficulty concentrating.

  • Past Psychiatric History: Diagnosed with depression in her early twenties, no history of manic episodes.

  • Medications: Currently not on any psychiatric medications.

  • Suicidal ideation: Denies current suicidal thoughts but admits to past passive thoughts of “wanting to just sleep and not wake up.”

  • Social History: Lives alone, works as a graphic designer, no significant substance use.

O - Objective:

  • Appearance: Appears disheveled, with poor grooming.

  • Speech: Slow speech, with low volume and a flat affect.

  • Behavior: Cooperative during interview but demonstrated psychomotor retardation (slower movement).

  • Mood: Depressed, as indicated by her facial expressions and slow responses.

  • Affect: Restricted range, primarily flat.

  • Thought process: Linear but slowed, with limited verbalization.

  • Cognition: Oriented to time, place, and person; able to recall recent and remote events.

  • Suicidal ideation: No active suicidal ideation, plan, or intent.

A - Assessment:

  • Diagnosis: Major Depressive Disorder (MDD), single episode, moderate severity.

  • Clinical reasoning: The patient presents with classic symptoms of depression, including low mood, anhedonia, sleep disturbances, and psychomotor retardation. There are no signs of mania, and she denies any substance use contributing to her symptoms.

P - Plan:

  • Medications: Start sertraline (Zoloft) 50 mg daily, titrate based on response.

  • Therapy: Recommend starting Cognitive Behavioral Therapy (CBT) weekly for the next 8 weeks.

  • Follow-up: Follow-up in 4 weeks for medication management and symptom reassessment.

  • Patient Education: Educate the patient on the importance of adherence to antidepressant therapy and that it may take 2–4 weeks to notice improvement in mood. Discuss the benefits of CBT for addressing negative thought patterns.

Example 2: Generalized Anxiety Disorder (GAD)

S - Subjective:

  • Chief Complaint: "I’m constantly worrying about everything, and it’s hard to relax."

  • History: A 40-year-old male reports chronic excessive worry over the past 6 months, primarily about work, finances, and health. The worry is often uncontrollable and difficult to manage, interfering with his ability to focus. He has difficulty falling asleep due to racing thoughts. He reports muscle tension and irritability.

  • Past Psychiatric History: No prior psychiatric diagnoses or hospitalizations.

  • Medications: Denies current medication use.

  • Substance Use: Occasional alcohol use (2-3 drinks/week), no illicit drug use.

  • Family History: Father had a history of anxiety.

O - Objective:

  • Appearance: Well-groomed, appropriately dressed.

  • Speech: Rapid speech, with signs of restlessness.

  • Behavior: Fidgeting, frequently shifting in his seat.

  • Mood: Anxious, as conveyed through speech and behavior.

  • Affect: Wide range, but often tense and restless.

  • Thought process: Logical, but disorganized due to constant worry.

  • Cognition: Alert and oriented, no cognitive impairment noted.

  • Physical Exam: Normal exam, no signs of physical illness.

A - Assessment:

  • Diagnosis: Generalized Anxiety Disorder (GAD).

  • Clinical reasoning: The patient’s excessive worry, restlessness, sleep disturbances, and muscle tension align with the diagnostic criteria for GAD. No signs of other mood or psychotic disorders were observed.

P - Plan:

  • Medications: Start escitalopram (Lexapro) 10 mg daily for anxiety.

  • Therapy: Refer for Cognitive Behavioral Therapy (CBT), particularly for relaxation techniques and cognitive restructuring.

  • Lifestyle Modifications: Recommend relaxation exercises, regular physical activity, and limiting caffeine intake.

  • Follow-up: Follow up in 2 weeks to assess medication efficacy and tolerability.

  • Patient Education: Discuss the potential side effects of SSRIs, including nausea, insomnia, and sexual dysfunction. Emphasize the importance of regular follow-up visits for medication management and symptom monitoring.

Conclusion: Writing Effective Psychiatric SOAP Notes

Writing effective psychiatric SOAP notes in NURS-6630N requires attention to detail, clear communication, and a comprehensive approach to documentation. Each section of the SOAP note plays a vital role in providing a complete picture of the patient’s mental health status, treatment plan, and ongoing care needs.

By following the structured format provided in this guide and using the examples as templates, you can ensure that your psychiatric SOAP notes are professional, concise, and clinically sound. These notes are not only essential for documentation but also crucial for clinical decision-making and effective patient care.