SOAP Note Examples - Templates for Every Specialty

S - Subjective

Client is a 52-year-old female who called in crisis after discovering her spouse has relapsed on opioids. She reported feeling terrified, angry, and helpless. She stated she found drug paraphernalia in the bathroom this morning. Client reported her teenage children do not know yet and she is worried about their safety. She denied any suicidal ideation but expressed hopelessness about the situation.

O - Objective

Client was emotionally distressed, speaking rapidly with intermittent crying. She was able to engage in problem-solving with support. Affect was labile, shifting between anger and sadness. She was oriented and coherent throughout the call. Safety assessment completed - no imminent danger to self or others. Client identified her sister as an immediate support person.

A - Assessment

Client is in acute psychosocial crisis related to spouse's substance use relapse. She is demonstrating appropriate emotional responses and maintains insight into the situation. The immediate safety of the children appears stable, though ongoing assessment is warranted. Client has at least one identified support person and is willing to engage in safety planning.

P - Plan

Provided immediate crisis counseling and emotional support. Developed safety plan including contact information for the substance abuse hotline, DV hotline, and emergency services. Referred spouse to the county substance abuse treatment program intake line. Scheduled emergency in-person session for tomorrow at 10am. Client agreed to contact her sister tonight for support. Will assess children's safety and potential CPS reporting needs at tomorrow's session.

S - Subjective

Student is a 14-year-old male referred by his teacher for declining grades and social withdrawal. He reported that his parents recently separated and his father moved out. He stated he feels angry at school and doesn't want to talk to his friends about what's happening at home. He denied any self-harm or suicidal thoughts. He expressed interest in joining the school's peer support group.

O - Objective

Student was initially reluctant to engage but became more open as the session progressed. He maintained intermittent eye contact and spoke in a quiet tone. Affect was flat but became more animated when discussing his interest in video game design. Academic records show a drop from B average to D average over the past marking period. Three disciplinary referrals for class disruption in the past month.

A - Assessment

Student is experiencing adjustment difficulties related to parental separation, manifesting as academic decline, behavioral changes, and social withdrawal. His willingness to engage in the session and interest in the peer support group are positive indicators. The pattern of acting out in class is likely an externalization of emotional distress. Protective factors include intellectual capability, at least one identified interest area, and willingness to accept support.

P - Plan

Enroll student in the school's weekly peer support group for children of divorce. Schedule individual check-ins biweekly. Coordinate with teachers to implement a brief check-in system during the school day. Contact mother to discuss home-school communication plan and community counseling referral. Notify the school counseling team for collaborative support.

S - Subjective

Client is a 34-year-old female in her 8th session of EMDR therapy for PTSD related to a motor vehicle accident 18 months ago. She reported that her nightmares have decreased from nightly to approximately twice per week. She stated she was able to drive on the highway for the first time since the accident, though she felt elevated anxiety during the drive. She rated her current distress related to the target memory at 4/10, down from 8/10 at initial assessment.

O - Objective

Client was appropriately dressed and punctual. Mood was described as 'cautiously optimistic.' Affect was congruent with mild residual anxiety. EMDR processing was performed on the target memory (moment of impact) using bilateral eye movements. Client reported emerging positive cognition 'I survived and I am safe now.' SUD level decreased from 4 to 2 during processing. VOC for positive cognition increased from 4 to 6. Body scan revealed residual tension in shoulders but no other somatic disturbance.

A - Assessment

Client is making significant progress in trauma processing. The decrease in SUD ratings, reduction in nightmare frequency, and ability to resume previously avoided driving activities all indicate positive treatment response. The emergence of the adaptive cognition 'I survived and I am safe now' suggests the memory network is being effectively reorganized. Remaining processing focuses on residual somatic responses.

P - Plan

Continue EMDR processing next session focusing on body scan closure for residual shoulder tension. Assign between-session practice of container exercise if distressing memories surface. Next session will also assess readiness to target the second cluster of memories (hospitalization experience). Continue weekly sessions. Reassess PCL-5 at session 10.

S - Subjective

Patient is a 45-year-old male who presents to the ED with complaint of severe chest pain rated 8/10, described as crushing and radiating to the left arm. Onset was approximately 30 minutes ago while watching television. He reports associated shortness of breath and diaphoresis. History of hypertension and hyperlipidemia. Current medications include lisinopril 10mg and atorvastatin 20mg daily. He denies recent illness, fever, or trauma.

O - Objective

VS: BP 168/98, HR 102, RR 22, Temp 98.4F, SpO2 94% on room air. Patient appeared diaphoretic and in moderate distress, clutching chest. Heart sounds regular, no murmur. Lungs clear bilaterally. 12-lead ECG obtained showing ST elevation in leads II, III, and aVF. Troponin drawn and sent to lab. Two large bore IVs placed. Aspirin 325mg chewed administered per protocol. Supplemental O2 at 4L nasal cannula initiated, SpO2 improved to 98%.

A - Assessment

Patient presenting with acute chest pain with ECG findings consistent with inferior STEMI. High acuity with hemodynamic instability (tachycardia, hypertension). Immediate cardiology consultation and cath lab activation warranted. Aspirin and oxygen interventions initiated per ACS protocol.

P - Plan

STEMI alert activated. Cardiology on call notified for emergent cardiac catheterization. Continue cardiac monitoring and serial vitals every 5 minutes. Administer heparin per protocol when ordered. Hold for cath lab transport. NPO status initiated. Notify family in waiting area of critical status. Pain reassessment after nitroglycerin administration.

S - Subjective

Patient is a 42-year-old male with major depressive disorder, recurrent, presenting for a medication follow-up. He has been on sertraline 100mg for 8 weeks. He reported that his mood has improved from 'barely functioning' to 'about 70% of normal.' Sleep has improved to 6-7 hours per night, up from 3-4 hours. He reports decreased appetite and a 5-pound weight loss over the past month. He denied side effects other than mild morning nausea that has improved. He denied suicidal or homicidal ideation.

O - Objective

Patient was well-groomed and cooperative. Psychomotor activity was within normal limits, improved from psychomotor retardation at initial visit. Speech was normal in rate and volume. Mood was 'better.' Affect was reactive and appropriate, a notable improvement from the flat affect observed 8 weeks ago. Thought process was linear and goal-directed. No perceptual disturbances. PHQ-9 score was 10, down from 22 at baseline. No SI/HI. Insight and judgment were good.

A - Assessment

Patient is demonstrating a partial response to sertraline 100mg after 8 weeks. PHQ-9 improvement from 22 to 10 indicates significant reduction in depressive symptoms, though residual moderate depression persists. The weight loss and decreased appetite warrant monitoring but may be related to the depression rather than medication side effects. Risk assessment is low with no suicidal ideation and improving functional status.

P - Plan

Increase sertraline to 150mg daily to target residual depressive symptoms. Monitor weight at next visit - if weight loss continues, consider switching to mirtazapine or adding a weight-neutral adjunct. Continue morning administration to minimize nausea. Encourage regular meals and physical activity. Follow-up in 4 weeks for reassessment. Repeat PHQ-9 and metabolic monitoring labs at next visit. Return sooner if symptoms worsen or SI develops.

S - Subjective

Patient is a 22-year-old female, 10 weeks post-op left ACL reconstruction with hamstring autograft. She reported she is able to walk without a brace for short distances at home. Pain rated 2/10 with exercise and 0/10 at rest. She has been compliant with her home exercise program but reports difficulty with terminal knee extension exercises. She expressed eagerness to return to recreational soccer.

O - Objective

Left knee AROM: flexion 128 degrees, extension -3 degrees (lacking 3 degrees of full extension). Patellar mobility was slightly restricted compared to the right. Quad strength was 4/5, hamstrings 4+/5. No effusion noted. Lachman test was negative for instability. Gait pattern was normal without assistive device on level surfaces, mild quad avoidance pattern noted on stairs. Performed: patellar mobilizations, quad sets with neuromuscular electrical stimulation, mini squats, standing hamstring curls, stationary bike 15 minutes.

A - Assessment

Patient is progressing well in ACL rehabilitation at 10 weeks post-op. Flexion ROM is ahead of protocol benchmarks. The slight extension deficit and restricted patellar mobility need to be addressed to prevent long-term complications. Quad strength deficit remains the primary impairment limiting function. Patient is appropriate to progress to Phase 3 (return-to-running) criteria assessment in 2 weeks pending quad strength improvement.

P - Plan

Continue PT 3x/week. Prioritize regaining full terminal extension: aggressive patellar mobilizations, prone hangs, low-load long-duration extension stretch. Progress strengthening to leg press and step-ups. Add proprioceptive training (single-leg balance, perturbation training). Update HEP with terminal knee extension emphasis. Begin straight-line jogging progression at week 12 if quad strength reaches 70% of uninvolved limb. Long-term goal: return to sport at 6-9 months post-op pending functional testing.

S - Subjective

Patient is a 48-year-old male carpenter, 4 weeks status post right distal radius fracture (ORIF). He reported stiffness and difficulty making a fist. Pain rated 3/10 with gripping activities. He expressed concern about returning to work and his ability to use power tools. He has been wearing his orthosis as prescribed and doing his HEP twice daily.

O - Objective

Right wrist AROM: flexion 35 degrees, extension 25 degrees, radial deviation 10 degrees, ulnar deviation 20 degrees. Grip strength (Jamar dynamometer): 22 lbs right, 95 lbs left (dominant). Pinch strength: lateral 8 lbs right, 22 lbs left. Mild edema noted at the dorsal wrist, circumference 18.5cm (left: 17cm). Sensation intact to light touch in all digital nerve distributions. Scar is well-healed, mildly adherent. Performed: scar massage, joint mobilizations (radiocarpal grade II), tendon gliding exercises, therapy putty gripping activities, and wrist AROM exercises in warm water.

A - Assessment

Patient is making expected progress at 4 weeks post-ORIF. Wrist ROM and grip strength are below functional thresholds for return to carpentry work, which requires sustained gripping and wrist loading. The edema and scar adherence are contributing to ROM limitations. Patient is compliant and motivated, which supports a positive rehabilitation outlook. Estimated 6-8 more weeks of therapy before return-to-work assessment.

P - Plan

Continue hand therapy 3x/week. Progress joint mobilizations to grade III as tolerated. Add resistance exercises: wrist curls, pronation/supination with 1 lb weight. Continue edema management with retrograde massage and compression. Begin work simulation tasks next week: hammer gripping, sustained grip endurance activities. Update orthosis to night-only wear. Refer to occupational health for formal functional capacity evaluation at week 10. Coordinate with employer regarding modified duty options.