SOAP Note Example
Psychiatry SOAP Note Example
Below is a complete SOAP note example for a psychiatry medication management visit with an adult patient diagnosed with major depressive disorder. This example demonstrates proper documentation of a full mental status exam, standardized outcome measures, current medications with doses, side effect assessment, medication adjustment rationale, and laboratory monitoring.
Complete Psychiatry Note
SUBJECTIVE:
Patient is a 45-year-old male presenting for a follow-up psychiatry medication management visit, 6 weeks after the most recent medication adjustment. Primary diagnosis: Major Depressive Disorder, recurrent, moderate (F33.1). Comorbid diagnosis: Generalized Anxiety Disorder (F41.1). Patient reports that his mood has been "a little better but still not where I want it to be." Describes most days as characterized by low motivation and difficulty initiating tasks — states he has a list of things he wants to do at home but "I sit on the couch and stare at it." Reports interest in activities has partially returned — he watched a basketball game with his brother last weekend and "actually cared who won," which he identifies as an improvement from 2 months ago when he "couldn't care less about anything." Sleep has improved since the dose increase at the last visit — now sleeping 6-7 hours per night compared to 4-5 hours previously, falling asleep within 30-40 minutes, but still waking once around 4 AM and sometimes unable to return to sleep. Reports appetite is fair — eating 2 meals per day, has regained 3 of the 12 pounds lost during the worst of the depressive episode. Energy remains his most significant complaint — rates it 3/10 most days, stating "I can get through work but I have nothing left when I get home." Concentration has modestly improved — able to complete work tasks but reports reading for pleasure remains difficult because he loses focus after a few pages. Reports anxiety is present but less prominent than the depression — describes intermittent worry about his job stability (his company went through layoffs 4 months ago) but states it is "not as constant as it was." Current medications: sertraline 150 mg daily (increased from 100 mg 6 weeks ago), trazodone 50 mg at bedtime as needed for sleep (using approximately 4-5 nights per week), lorazepam 0.5 mg as needed for acute anxiety (patient reports using approximately 2 tablets per month, no increase in frequency). Side effects: reports mild headache in the first week after the sertraline dose increase, which resolved spontaneously. Endorses mild sexual dysfunction — delayed ejaculation that began approximately 3 weeks ago. Denies nausea, diarrhea, dizziness, tremor, excessive sweating, or weight gain attributable to medication. Denies dry mouth, constipation, or cognitive dulling from trazodone. Patient completed the PHQ-9 in the waiting room — score: 12 (moderate depression), compared to 18 (moderately severe) at the last visit 6 weeks ago and 22 (severe) at initial presentation 4 months ago. GAD-7 score: 8 (mild anxiety), compared to 14 (moderate) at the last visit. Denies suicidal ideation — states "I'm not there — I want to feel better, not give up." Denies prior suicide attempts, self-harm behaviors, and homicidal ideation. Alcohol use: 1-2 beers on weekends, unchanged. Denies cannabis, nicotine, or other substance use. Patient reports he started individual therapy 3 weeks ago with a licensed psychologist, Dr. Karen Liu, and has attended 3 weekly sessions focused on behavioral activation and cognitive restructuring. States therapy has been "good — she's helping me break things into smaller steps." Labs drawn 3 days ago per this provider's order — patient states he completed the fasting blood draw at the outpatient lab and asks about results.
OBJECTIVE:
Mental Status Exam: Appearance — 45-year-old male who appears his stated age, casually dressed in jeans and a flannel shirt, grooming adequate but hair unkempt, no unusual odors. Psychomotor activity — mildly slowed, noted in deliberate movements when entering the office and sitting down; no agitation, no tremor, no abnormal involuntary movements. Eye contact — fair initially, improving as the session progressed to consistent and appropriate. Speech — slightly reduced in rate and volume at baseline; became more spontaneous and animated when discussing the basketball game with his brother; no pressured speech, no poverty of speech. Mood — "better but still low" (patient's words). Affect — dysthymic at baseline, constricted range but reactive — brightened when discussing therapy and the basketball game, became more subdued when discussing energy and concentration difficulties; affect congruent with mood and content throughout. Thought process — linear, logical, goal-directed, no loosening of associations, no tangentiality, no flight of ideas. Thought content — preoccupied with fatigue and functional limitations; no delusions, no paranoid ideation, no ideas of reference, no obsessive or ritualistic thinking. Suicidal ideation — denied, no passive death wish. Homicidal ideation — denied. Perceptions — no auditory or visual hallucinations reported or observed, no illusions. Cognition — alert and oriented to person, place, time, and situation; attention intact (able to recite months of the year backward without error); recent and remote memory grossly intact by conversational assessment. Insight — good; understands that he has a depressive illness that requires pharmacological and psychotherapeutic treatment, recognizes partial improvement and remaining deficits. Judgment — intact; making appropriate decisions including initiating therapy, maintaining medication compliance, and reducing alcohol from prior levels. Risk assessment: current suicidal ideation — denied; passive death wish — denied; prior attempts — none; self-harm — denied; homicidal ideation — denied; access to firearms — hunting rifles in the home, stored in a locked gun safe, patient states he gave the key to his brother 3 months ago at this provider's recommendation and has not retrieved it; substance use — stable and low-risk; protective factors — engaged in outpatient treatment (psychiatry and therapy), family support (close relationship with brother), employed, future-oriented thinking, denied hopelessness. Current risk level: low. PHQ-9 score: 12 (moderate depression). Score trajectory: initial presentation 22 (severe), week 4 on sertraline 100 mg — 20 (severe, minimal change), week 8 after increase to sertraline 150 mg (6 weeks ago) — 18 (moderately severe), today (week 14, 6 weeks at 150 mg) — 12 (moderate). Six-point decrease over the past 6 weeks since dose increase, indicating a clinically significant response. GAD-7 score: 8 (mild anxiety). Score trajectory: initial 16 (severe), week 4 — 14, week 8 — 14, today — 8 (mild). Notable improvement in anxiety concurrent with depression improvement. Laboratory results (fasting, drawn 03/26/2026): Complete Metabolic Panel — glucose 94 mg/dL (reference 70-100), BUN 16 mg/dL (reference 7-20), creatinine 1.0 mg/dL (reference 0.7-1.3), sodium 141 mEq/L (reference 136-145), potassium 4.3 mEq/L (reference 3.5-5.0), chloride 102 mEq/L (reference 98-106), CO2 25 mEq/L (reference 23-29), calcium 9.6 mg/dL (reference 8.5-10.5), total protein 7.1 g/dL (reference 6.0-8.3), albumin 4.2 g/dL (reference 3.5-5.5), AST 22 U/L (reference 10-40), ALT 28 U/L (reference 7-56), alkaline phosphatase 68 U/L (reference 44-147), total bilirubin 0.8 mg/dL (reference 0.1-1.2). Thyroid panel: TSH 2.4 mIU/L (reference 0.4-4.0), free T4 1.1 ng/dL (reference 0.8-1.8). CBC: WBC 6.8 x10^3/uL (reference 4.5-11.0), hemoglobin 14.8 g/dL (reference 13.5-17.5), hematocrit 44.2% (reference 38.3-48.6), platelets 238 x10^3/uL (reference 150-400). Lipid panel: total cholesterol 198 mg/dL, LDL 118 mg/dL, HDL 48 mg/dL, triglycerides 160 mg/dL. All laboratory values within normal reference ranges. Thyroid function normal — hypothyroidism excluded as contributing factor to depressive symptoms and fatigue.
ASSESSMENT:
Patient is a 45-year-old male with Major Depressive Disorder (recurrent, moderate) and comorbid Generalized Anxiety Disorder demonstrating a clinically significant but partial response to sertraline 150 mg daily over 6 weeks. PHQ-9 has decreased from 18 to 12 (6-point reduction, exceeding the 5-point clinically significant threshold), and GAD-7 has decreased from 14 to 8. Subjective improvements are consistent with these scores — partial return of interest (anhedonia improving), improved sleep architecture, and modest appetite and concentration recovery. The primary residual symptoms are significant fatigue, psychomotor slowing, and motivational impairment — these anergia-predominant residual symptoms suggest that serotonergic augmentation alone may be insufficient and that a medication with noradrenergic or dopaminergic activity may benefit this patient. The sexual dysfunction (delayed ejaculation) is a common SSRI side effect that began approximately 3 weeks after the dose increase and is likely dose-related. While the patient has not identified it as a major concern, it should be monitored as it is a common reason for medication discontinuation. Laboratory evaluation is reassuring — thyroid function is normal, ruling out hypothyroidism as a contributing factor to fatigue; metabolic panel and hepatic function are normal, supporting continued sertraline use; CBC is normal with no hematologic concerns. The patient's initiation of cognitive behavioral therapy 3 weeks ago is a positive prognostic factor — combined pharmacotherapy and psychotherapy for MDD yields higher remission rates than either modality alone. Lorazepam use remains low (2 tablets per month) and does not suggest a pattern of escalation. Trazodone is providing benefit for sleep maintenance without side effects. Current risk is low with active protective measures in place including firearm restriction. Overall trajectory is positive but the patient has not yet reached remission (PHQ-9 target less than 5) and significant functional impairment remains, warranting continued optimization of the pharmacotherapy regimen.
PLAN:
Medication changes: add bupropion SR 150 mg daily in the morning as augmentation to sertraline — clinical rationale: bupropion's noradrenergic and dopaminergic mechanism addresses the residual fatigue, psychomotor slowing, and motivational impairment that are not responding to serotonergic treatment alone; bupropion may also mitigate the SSRI-related sexual dysfunction. Start at 150 mg SR once daily for 2 weeks, then increase to 150 mg SR twice daily (morning and early afternoon, no later than 2 PM to avoid insomnia) if tolerated. Patient counseled on expected onset of effect (2-4 weeks for full benefit), potential side effects to monitor (insomnia, dry mouth, headache, appetite suppression, and the rare risk of seizures at higher doses — patient confirmed no history of seizures, eating disorders, or heavy alcohol use, which are contraindications). Continue sertraline 150 mg daily — no dose change at this time; the addition of bupropion is preferred over a further sertraline increase given the side effect profile (sexual dysfunction may worsen with higher SSRI dose) and the specific residual symptom cluster (anergia responds better to noradrenergic/dopaminergic augmentation than to additional serotonergic activity). Continue trazodone 50 mg at bedtime as needed for sleep. Continue lorazepam 0.5 mg as needed for acute anxiety — monitor frequency; if the bupropion augmentation improves residual anxiety through improved overall functioning and energy, the patient may use it less frequently. Monitor for serotonin syndrome risk — bupropion does not significantly increase this risk, but patient was counseled to report tremor, agitation, diaphoresis, or confusion immediately. Sexual dysfunction: monitor over the next 6 weeks — if delayed ejaculation persists or worsens despite the potential mitigating effect of bupropion, options include sertraline dose reduction (if depression is in remission), switching to a medication with lower sexual side effect risk, or adding a targeted intervention. Follow-up laboratory monitoring: repeat fasting metabolic panel and lipid panel in 3 months; thyroid panel annually unless clinically indicated sooner. Continue individual therapy with Dr. Liu — behavioral activation and cognitive restructuring are well-targeted to this patient's residual motivational and concentration symptoms. Safety: continue current firearm access restriction (key with brother); reassess at each visit. Patient to call the clinic or present to the emergency department if he experiences worsening depression, emergence of suicidal ideation, or significant side effects from the new medication. 988 Suicide & Crisis Lifeline reinforced. Next visit in 4 weeks to assess bupropion response and tolerability, readminister PHQ-9 and GAD-7, and evaluate sexual dysfunction status. Long-term treatment goals: achieve PHQ-9 remission (score less than 5), restore functional energy to 7/10 or above, resume leisure activities including reading, maintain current work performance, and resolve or manage sexual side effects to a level acceptable to the patient. If PHQ-9 does not reach the mild range (less than 10) within 8 weeks of bupropion augmentation at full dose, consider further augmentation strategies (lithium, atypical antipsychotic augmentation) or referral for treatment-resistant depression evaluation.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Psychiatry medication management notes require a systematic review of each target symptom of the diagnosed condition — for MDD, this includes mood, anhedonia, sleep, appetite/weight, energy, concentration, psychomotor changes, guilt, and suicidality. Use specific comparisons to prior visits and baseline (sleeping 6-7 hours now vs. 4-5 previously, regained 3 of 12 lost pounds) to quantify improvement rather than relying on vague descriptors. Document every current medication with exact dose, frequency, duration at current dose, adherence pattern, and a specific side effect review for each — this is the core clinical data of a medication management visit. Include the PHQ-9 and GAD-7 scores with comparison to prior visits to establish the treatment response trajectory. Document substance use at each visit because it affects pharmacotherapy decisions and risk. Note concurrent psychotherapy with the provider's name, frequency, and modality, as combined treatment is the standard of care for moderate-to-severe MDD.
Objective
The full mental status exam (MSE) is the cornerstone of the psychiatric objective section — it is the psychiatrist's equivalent of a physical exam and must be documented systematically at every visit. Cover all domains: appearance, psychomotor activity, eye contact, speech, mood (patient's words in quotes), affect (your clinical observation with specific descriptors for range, reactivity, and congruence), thought process, thought content, suicidal and homicidal ideation, perceptions, and cognition. Follow the MSE with a structured risk assessment that addresses ideation, plan, intent, access to means (including the specific status of any firearm safety measures), substance use, and protective factors, then state the risk level. Document standardized assessment score trajectories over the full course of treatment (PHQ-9 at each visit from intake to present) — this data drives medication decisions and demonstrates treatment response to insurance reviewers. Include all relevant laboratory results with reference ranges and your clinical interpretation of their significance (thyroid normal, ruling out hypothyroidism as contributing factor).
Assessment
The psychiatric assessment is where clinical pharmacology reasoning is documented. Characterize the treatment response — partial response, full response, non-response — using both standardized scores and symptom-level analysis. Identify the residual symptom cluster and explain why it informs your medication strategy (anergia-predominant residual symptoms suggesting the need for noradrenergic or dopaminergic augmentation rather than further serotonergic dose increase). Address each side effect with your clinical interpretation (sexual dysfunction is likely dose-related SSRI effect, onset timing supports this). Interpret laboratory results in the context of the differential diagnosis (normal TSH rules out thyroid contribution to fatigue). Comment on the role of concurrent psychotherapy in the treatment plan. Assess the overall trajectory and state whether the patient is moving toward remission, and if not, what pharmacotherapy optimization steps remain available. This level of reasoning distinguishes a medication management note from a medication check.
Plan
The psychiatry plan must provide explicit medication decisions with clinical rationale for every change — name the medication being added or adjusted, the target dose and titration schedule, the specific symptoms it targets, and why it was chosen over alternatives (bupropion for anergia and potential sexual dysfunction mitigation versus further SSRI dose increase that might worsen sexual side effects). Include patient counseling provided (expected onset, side effects, contraindications reviewed). Document monitoring plans for both efficacy (PHQ-9 and GAD-7 at next visit, specific symptom targets) and safety (lab schedule, serotonin syndrome awareness, seizure risk counseling). Address each concurrent medication — continue, adjust, or taper — with reasoning. Include a clear escalation plan if the current strategy does not achieve the desired response within a defined timeframe (consider augmentation strategies or treatment-resistant depression referral if PHQ-9 does not reach mild range within 8 weeks). This demonstrates thoughtful, evidence-based prescribing and ensures continuity if another provider covers the case.
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