SOAP Note Example
Telehealth SOAP Note Example
Below is a complete SOAP note example for a telehealth follow-up visit with an adult patient managing generalized anxiety disorder via video-based care. This example demonstrates proper documentation of telehealth-specific elements including informed consent, technology platform, patient location, audio/video quality, and the modified physical assessment approach required for remote encounters.
Complete Telehealth Note
SUBJECTIVE:
Telehealth visit conducted via HIPAA-compliant video platform (Doxy.me). Patient connected from her home in Austin, Texas (confirmed verbally at start of visit). Verbal informed consent for telehealth services obtained and documented — patient acknowledged understanding of the benefits, risks, limitations, and alternatives to telehealth, including the option for an in-person visit. Audio and video quality: clear throughout the session with no significant interruptions; patient was visible from the chest up with adequate lighting; one brief connectivity drop at approximately 18 minutes into the session lasting approximately 10 seconds, reconnected automatically without loss of clinical content. Patient is a 38-year-old female presenting for a follow-up telehealth visit for management of generalized anxiety disorder (F41.1), 8 weeks after initiating treatment. Current medications: escitalopram 10 mg daily (started 8 weeks ago by this provider), melatonin 3 mg at bedtime as needed. Patient reports that anxiety symptoms have "improved but are still there, especially at work." Describes worry as less pervasive than at treatment initiation — previously described anxiety as "constant and out of control" and now reports it is "manageable most of the day but spikes during meetings and before deadlines." Sleep has improved — falling asleep within 30 minutes most nights compared to 60-90 minutes at intake, sleeping 6-7 hours per night compared to 4-5 hours at intake, waking feeling more rested. Reports using the melatonin 2-3 nights per week. Appetite is normal, no weight changes noticed. Denies gastrointestinal side effects from escitalopram — reports mild nausea during the first 2 weeks that has since fully resolved. Reports no sexual dysfunction, no headaches, no dizziness, and no increased bruising or bleeding. Denies any new physical symptoms. Patient completed the GAD-7 via the patient portal prior to this visit — score: 9 (mild anxiety), compared to 16 (severe) at the initial visit 8 weeks ago. Reports she has been attending weekly therapy sessions with her counselor (licensed professional counselor, Dr. Amanda Chen) and is practicing cognitive behavioral therapy skills including thought records and scheduled worry time. States therapy has been "really helpful for catching the spiraling thoughts before they take over." Denies suicidal ideation, homicidal ideation, and self-harm urges. Denies increased alcohol or substance use. Reports social functioning has improved — went to a friend's birthday dinner last week for the first time in months and "actually enjoyed it." Patient's work performance review is upcoming in 2 weeks, which she identifies as a significant anticipated stressor.
OBJECTIVE:
Telehealth-modified assessment — the following observations were made via video. General appearance: patient is seated in a well-lit room at a desk, appears well-groomed and appropriately dressed in casual clothing. No acute distress observed. Mental status exam (via video): Behavior — cooperative, engaged, maintained appropriate eye contact with camera, no psychomotor agitation or retardation. Speech — normal rate, rhythm, and volume; spontaneous and well-organized. Mood — "better but still anxious about work" (patient's words). Affect — mood-congruent, mild anxiety noted when discussing upcoming performance review, appropriate range and reactivity, brightened when discussing social engagement at the friend's dinner. Thought process — linear, logical, goal-directed, no tangentiality or circumstantiality. Thought content — preoccupied with work performance evaluation; no delusions, no obsessional content, no paranoid ideation. Perceptions — no auditory or visual hallucinations reported or observed. Cognition — alert and oriented to person, place, time, and situation; concentration appeared intact throughout the 30-minute session; engaged fully in discussion and responded appropriately to all questions. Insight — good; demonstrates understanding of the relationship between cognitive patterns and anxiety symptoms, and is actively applying CBT skills between sessions. Judgment — intact; recent decisions are appropriate and health-seeking (attending therapy, taking medication as prescribed, re-engaging socially). Risk assessment: suicidal ideation — denied; homicidal ideation — denied; self-harm — denied; access to means — not assessed this visit (assessed as negative at initial intake visit); substance use changes — denied; protective factors — engaged in therapy, supportive friend group, stable employment, medication compliance, future-oriented thinking. Current risk level: low. Physical assessment limitations (telehealth): vital signs not obtained (patient does not have home blood pressure monitor or pulse oximeter); full physical examination not performed — deferred to next in-person visit or as clinically indicated. Observed via video: no visible rashes, lesions, or swelling on face, neck, or upper extremities; no apparent tremor in hands during session; no visible diaphoresis; patient appeared well-nourished with no notable weight change from visual comparison to prior visits. GAD-7 score: 9 (mild anxiety) — administered via patient portal prior to visit. Score trajectory: intake 16 (severe), week 4 visit 12 (moderate), week 8 visit (today) 9 (mild). Medication review: escitalopram 10 mg daily — patient reports taking consistently every morning with breakfast, no missed doses in the past 2 weeks; melatonin 3 mg at bedtime — using 2-3 nights per week as needed, reports it is effective for sleep onset.
ASSESSMENT:
Patient is a 38-year-old female with generalized anxiety disorder (F41.1) showing meaningful clinical improvement over 8 weeks of combined pharmacotherapy (escitalopram 10 mg) and cognitive behavioral therapy. GAD-7 has decreased from 16 (severe) at intake to 9 (mild) at today's visit — a 7-point reduction that exceeds the clinically significant change threshold of 4 points, indicating a robust treatment response. Sleep quality and duration have significantly improved (sleep onset reduced from 60-90 minutes to 30 minutes, total sleep increased from 4-5 hours to 6-7 hours), social functioning is improving (re-engaging with friends after a period of avoidance), and the patient is actively and effectively utilizing CBT skills in her daily life. Escitalopram is well-tolerated — initial nausea resolved within 2 weeks, and the patient denies sexual dysfunction, headaches, or other side effects. Residual anxiety is predominantly situational and work-related (meetings, deadlines, upcoming performance review) rather than the pervasive and uncontrollable worry reported at intake, suggesting a shift from generalized to more circumscribed anxiety as treatment progresses. Current escitalopram dose of 10 mg appears to be at a therapeutic level given the strong symptom trajectory, but the dose has room for increase (max 20 mg) if the GAD-7 plateaus above the target range. The upcoming performance review in 2 weeks is an anticipated stressor that may temporarily increase symptoms — proactive coping planning is warranted. Continued combined treatment with pharmacotherapy and CBT is clinically appropriate. Risk remains low with multiple protective factors in place. Telehealth modality is appropriate for this patient — she is clinically stable, engaged, and the visit format supports medication monitoring and care coordination effectively.
PLAN:
Continue escitalopram 10 mg daily — no dose adjustment at this time given the strong improvement trajectory (GAD-7 from 16 to 9 over 8 weeks). If GAD-7 plateaus above 7 at the next visit or symptoms increase significantly around the performance review, consider increasing to 15 mg. Continue melatonin 3 mg at bedtime as needed for sleep onset. Discussed proactive coping strategies for the upcoming performance review: patient will use the worry time technique from CBT to contain anticipatory anxiety to a designated 15-minute period daily, will prepare a written summary of her accomplishments to reference before the review meeting, and agreed to discuss the performance review anxiety with her therapist Dr. Chen at this week's session. Encouraged continued weekly CBT sessions. Patient to complete GAD-7 via the patient portal 1-2 days before the next visit. In-person visit recommended within the next 2-3 months for comprehensive vital signs, physical exam, and baseline weight documentation — patient agreed to schedule this as her next visit. Follow-up telehealth visit in 4 weeks (approximately 2 weeks after the performance review) to assess the impact of that stressor and continued medication response. Safety: patient instructed to contact the clinic or go to the nearest emergency department if she develops suicidal thoughts, intends to harm herself or others, or experiences a significant acute deterioration in functioning. 988 Suicide & Crisis Lifeline number reinforced. Long-term treatment goals: maintain GAD-7 in the minimal range (0-4), sustain social engagement, maintain sleep quality with eventual discontinuation of melatonin, and develop independent mastery of CBT coping skills. Reassess at 6 months of treatment for potential medication continuation, dose reduction, or taper planning based on sustained symptom remission.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Telehealth SOAP notes must begin with telehealth-specific documentation elements before the clinical narrative: the platform used (name the HIPAA-compliant software), the patient's physical location (state matters for licensure compliance), informed consent status, and audio/video quality including any disruptions during the session. These elements are legal and billing requirements — payers and auditors look for them specifically. The clinical content follows the same principles as an in-person visit: patient self-report, medication adherence and side effects, symptom changes with specific comparisons to baseline, standardized screening scores (GAD-7), and risk screening. Include coordination of care information such as concurrent therapy with another provider by name, as this demonstrates integrated treatment and supports the medical necessity of the medication management visit.
Objective
The objective section in a telehealth note must explicitly acknowledge what can and cannot be assessed remotely. A full mental status exam is feasible via video and should be documented in the same systematic format used for in-person visits — appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. However, you must clearly state that vital signs were not obtained and that a physical examination was not performed, noting the reason (telehealth modality, no home monitoring equipment). Document any observations you can make via video — visible skin, apparent weight change, presence or absence of tremor, diaphoresis, or acute distress. Include the standardized assessment score trajectory over time (GAD-7 at intake, week 4, and week 8) to demonstrate measurable progress. This transparency about assessment limitations protects you legally and demonstrates clinical thoroughness.
Assessment
The assessment for a telehealth visit should include your clinical interpretation of symptom trajectory, medication efficacy and tolerability, and the appropriateness of the telehealth modality for this specific patient. Reference the clinically significant change threshold for your outcome measure (GAD-7 change of 4 or more points) to demonstrate that improvement is not just numerical but clinically meaningful. Identify residual symptoms and characterize how they have changed — shifting from pervasive to situational anxiety is a qualitative improvement worth documenting. Include your reasoning for maintaining, adjusting, or changing the medication dose so the decision is transparent. Comment explicitly on whether telehealth remains appropriate for the patient's current clinical status or whether an in-person visit is indicated — this demonstrates ongoing modality assessment, which payers and licensing boards expect.
Plan
The telehealth plan should address medication decisions with explicit criteria for future dose changes (if GAD-7 plateaus above target), coordination with other providers (therapist), homework or coping strategies for anticipated stressors, and the timing and modality of the next visit. Critically, include a plan for an in-person visit at a defined interval for vital signs and physical examination — this demonstrates you are managing the limitations of the telehealth modality responsibly. Document safety instructions including crisis resources (988 Lifeline) and clear criteria for seeking emergency care. Long-term treatment planning with specific timelines for reassessing the need for continued medication shows that the treatment is goal-directed with a defined endpoint, not indefinite maintenance by default.
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