Free SOAP Note Generator for Mental Health
Generate complete mental health SOAP notes with AI. Tailored for psychiatric assessments, medication management, mental status examinations, and behavioral health documentation.
Mental Health SOAP Notes
Mental health SOAP notes are used across psychiatric, psychological, and behavioral health settings. They document the patient's mental status, medication response, risk assessment, and treatment planning. These notes are essential for continuity of care, particularly when multiple providers are involved.
Key Components for Mental Health Documentation
S - Subjective
Document the patient's self-reported symptoms, mood, medication effects and side effects, sleep quality, appetite, energy level, and psychosocial stressors. Note any changes since the last visit and the patient's own assessment of their progress.
O - Objective
Include the mental status examination: appearance, behavior, speech, mood, affect, thought process, thought content (including suicidal/homicidal ideation), perception, cognition, insight, and judgment. Add vital signs if relevant, standardized assessment scores, and medication compliance data.
A - Assessment
Provide clinical impression including diagnostic considerations, risk assessment (SI/HI/violence), medication efficacy evaluation, and progress toward treatment goals. Note any changes in clinical picture or diagnostic formulation.
P - Plan
Outline medication changes or continuations with dosages, therapy recommendations, safety planning if indicated, lab orders, lifestyle recommendations, and follow-up timeline.
Common Mental Health Assessment Tools
| Tool | Purpose |
|---|---|
| PHQ-9 | Depression severity (0-27 scale) |
| GAD-7 | Generalized anxiety severity |
| C-SSRS | Suicide risk screening |
| MDQ | Mood Disorder Questionnaire (bipolar screening) |
| PCL-5 | PTSD symptom checklist |
| MMSE / MoCA | Cognitive screening |
Mental Health SOAP Note Example
S - Subjective
Patient is a 28-year-old female with bipolar II disorder presenting for medication management follow-up. She reported improved mood stability over the past month since lamotrigine was increased to 200mg. She described sleeping approximately 7 hours per night with improved sleep quality. She denied any suicidal or homicidal ideation. She reported some mild fatigue in the afternoons but otherwise tolerating the medication well.
O - Objective
Patient was well-groomed, casually dressed, and cooperative. Speech was normal in rate, rhythm, and volume. Mood was described as "pretty good." Affect was euthymic and congruent. Thought process was linear and goal-directed. No suicidal or homicidal ideation, no hallucinations or delusions. Insight and judgment were intact. PHQ-9 score was 8, down from 14 at last visit.
A - Assessment
Patient is demonstrating significant improvement in mood stability with the lamotrigine dose increase. PHQ-9 score improvement from 14 to 8 supports clinical observation of reduced depressive symptoms. Risk assessment is low - no active suicidal ideation, intact protective factors. Current medication regimen appears effective.
P - Plan
Continue lamotrigine 200mg daily. Monitor for fatigue - if persistent, consider timing adjustment. Continue individual therapy weekly with current therapist. Order comprehensive metabolic panel and thyroid panel at next visit. Follow-up appointment in four weeks for medication management. Return sooner if mood destabilization occurs.
Frequently Asked Questions
What is a mental status examination (MSE)?
The MSE is a systematic assessment of a patient's current mental state. It evaluates appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. It forms the core of the Objective section in mental health SOAP notes.
How do I document suicidal ideation in a SOAP note?
Document the presence or absence of suicidal ideation in both the Subjective (patient's report) and Objective (your clinical assessment) sections. If present, note the nature (passive vs active), plan, intent, means access, and protective factors. Include safety planning in the Plan section.