Initial Psychiatric SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting.
Criteria Clinical Notes
Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient the ability/capacity to
respond and appears to the risk, benefits, and (Will review additional consent during
treatment plan discussion)
Subjective Verify Patient
Verify Patient: Name, Name:
Assigned identificati DOB:
on number (e.g.,
medical record
number), Date of Minor:
birth, Phone number, Accompanied by:
Social security
number, Address, Demographic:
Photo.
Gender Identifier Note:
Include
demographics, chief CC:
complaint, subjective
information from the HPI:
patient, names and
relations of others Pertinent history in record and from patient: X
present in the
interview. During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
HPI: Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report
libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria.
Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level,
, Past Medical and attention and concentration were observed to be within normal limits. Patient does not report symptoms of
Psychiatric History, eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a
Current Medications, characterological nature.
Previous Psych Med
trials, SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies inappropriate/illegal behaviors.
NW_11/1/20
This study source was downloaded by 100000900412927 from CourseHero.com on 12-22-2025 13:36:33 GMT -06:00
https://www.coursehero.com/file/238120252/Psychiatric-SOAP-Note-Template-for-Clinical-Practice/
, Allergies.
Social History, Family Allergies: NKDFA.
History. (medication & food)
Review of Systems
(ROS) – if ROS is Past Medical Hx:
negative, “ROS Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
noncontributory,” or Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
“ROS negative with Surgical history no surgical history reported
the exception of…”
If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early
childhood, school hx, behavior, etc…
Nutritional status (this is an important component to gauge how well the mind and body are being nourished
for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which
affects function of cognition, mood, etc…)
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Auditory Hallucinations:
Visual Hallucinations:
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing
disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Current Medications: No current medications.
(Contraceptives):
Supplements:
Past Psych Med Trials:
NW_11/1/20
This study source was downloaded by 100000900412927 from CourseHero.com on 12-22-2025 13:36:33 GMT -06:00
https://www.coursehero.com/file/238120252/Psychiatric-SOAP-Note-Template-for-Clinical-Practice/
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective,
Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to
develop your style of SOAP in the psychiatric practice setting.
Criteria Clinical Notes
Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy
treatment. Verbal and Written consent obtained. Patient the ability/capacity to
respond and appears to the risk, benefits, and (Will review additional consent during
treatment plan discussion)
Subjective Verify Patient
Verify Patient: Name, Name:
Assigned identificati DOB:
on number (e.g.,
medical record
number), Date of Minor:
birth, Phone number, Accompanied by:
Social security
number, Address, Demographic:
Photo.
Gender Identifier Note:
Include
demographics, chief CC:
complaint, subjective
information from the HPI:
patient, names and
relations of others Pertinent history in record and from patient: X
present in the
interview. During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
HPI: Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report
libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria.
Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level,
, Past Medical and attention and concentration were observed to be within normal limits. Patient does not report symptoms of
Psychiatric History, eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a
Current Medications, characterological nature.
Previous Psych Med
trials, SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent
behavior, denies inappropriate/illegal behaviors.
NW_11/1/20
This study source was downloaded by 100000900412927 from CourseHero.com on 12-22-2025 13:36:33 GMT -06:00
https://www.coursehero.com/file/238120252/Psychiatric-SOAP-Note-Template-for-Clinical-Practice/
, Allergies.
Social History, Family Allergies: NKDFA.
History. (medication & food)
Review of Systems
(ROS) – if ROS is Past Medical Hx:
negative, “ROS Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
noncontributory,” or Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
“ROS negative with Surgical history no surgical history reported
the exception of…”
If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early
childhood, school hx, behavior, etc…
Nutritional status (this is an important component to gauge how well the mind and body are being nourished
for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which
affects function of cognition, mood, etc…)
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Auditory Hallucinations:
Visual Hallucinations:
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing
disturbing events.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Current Medications: No current medications.
(Contraceptives):
Supplements:
Past Psych Med Trials:
NW_11/1/20
This study source was downloaded by 100000900412927 from CourseHero.com on 12-22-2025 13:36:33 GMT -06:00
https://www.coursehero.com/file/238120252/Psychiatric-SOAP-Note-Template-for-Clinical-Practice/
