Psychiatric SOAP Notes: Complete Guide 2026

Chief Complaint: "I can't shake this sadness and I have no energy."

History of Present Illness: Patient is a 32-year-old female presenting for initial psychiatric evaluation with complaints of depressed mood, anhedonia, and fatigue for approximately 6 weeks. She reports the onset coincided with a job loss 2 months ago. Patient describes mood as "heavy" and rates it 3/10 (10 being best). She reports:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest in activities she previously enjoyed
- Insomnia with early morning awakening (waking at 4 AM, unable to return to sleep)
- Fatigue and loss of energy daily
- Feelings of worthlessness ("I feel like a failure")
- Difficulty concentrating at tasks, described as "brain fog"
- Decreased appetite with 8 lb weight loss over 6 weeks
- Passive suicidal ideation ("sometimes I think everyone would be better off without me") but denies plan, intent, or means

Patient denies manic or hypomanic episodes, psychotic symptoms, or panic attacks. She reports increased anxiety related to financial stressors.

Past Psychiatric History: No prior psychiatric hospitalizations. Reports "mild depression" in college that resolved without treatment. No prior psychotropic medications.

Substance Use: Alcohol 1-2 glasses of wine on weekends (unchanged). Denies tobacco, illicit drugs, or cannabis.

Medical History: Hypothyroidism (on levothyroxine 50mcg daily), no other medical conditions.

Family Psychiatric History: Mother with depression and anxiety, treated with Lexapro. Maternal grandmother hospitalized for "nervous breakdown" (details unknown).

Social History: Single, lives alone in apartment. Recently lost marketing job due to company layoffs. BA in Communications. Good support from friends and sister. No children.

Chief Complaint: "Feeling more stable, but still having some down days."

Interval History: 45-year-old male with Bipolar I Disorder presenting for routine medication management follow-up, 4 weeks since last visit. Patient reports overall improvement in mood stability on current regimen. He describes:
- Mood has been "more even" with fewer extreme swings
- Some residual low mood days, 2-3 per week, lasting hours not days
- Sleep improved to 7 hours nightly (previously 4-5 hours)
- No recent manic symptoms (no decreased need for sleep, grandiosity, pressured speech, or impulsive behavior)
- Energy level "better but not 100%"
- Concentration improved, able to focus at work
- Denies suicidal or homicidal ideation
- Denies psychotic symptoms

Medication Compliance: Taking lithium 900mg daily as prescribed. Denies missed doses. Reports mild hand tremor but tolerable. Increased thirst and urination noted but manageable.

Substance Use: Quit alcohol 6 months ago per recommendation. Denies all substances.

Stressors: Work going well. Marriage stable. Financial stress improving.

Last manic episode: 8 months ago (resulted in brief hospitalization)
Last depressive episode: Recovering from episode that prompted lithium increase 6 weeks ago

Chief Complaint: "My anxiety is definitely better since we started the thought challenging."

Interval History: 28-year-old female with Generalized Anxiety Disorder presenting for 8th session of CBT. Patient reports continued improvement in anxiety symptoms since initiating treatment. She describes:
- Overall anxiety level 4/10 (was 8/10 at intake)
- Less frequent "worry spirals" - now once per week vs daily
- Using cognitive restructuring techniques regularly
- Improved sleep - falling asleep within 20 minutes (was 60+ minutes)
- Less physical symptoms (muscle tension, headaches reduced)
- Successfully used exposure techniques at work presentation last week
- Reports feeling "more in control" of anxious thoughts

Current anxiety triggers: Work deadlines, health concerns (fears about minor symptoms)

Coping strategies being used:
- Thought records 3-4x weekly
- Diaphragmatic breathing when anxious
- Behavioral experiments (testing predictions)
- Scheduled worry time (containing worry to 15 min/day)

Patient reports homework completion (thought records) approximately 70% of the time.

No medication - patient declined pharmacotherapy, prefers therapy-only approach.

Denies panic attacks, avoidance behaviors, OCD symptoms, or depressive symptoms.
Denies suicidal or homicidal ideation.

Chief Complaint: "The nightmares are less frequent. I'm starting to feel like myself again."

Interval History: 35-year-old male veteran with combat-related PTSD presenting for session 10 of Prolonged Exposure (PE) therapy. Patient reports continued progress with trauma processing. He describes:

- Nightmares reduced to 1-2x/week (was nightly at intake)
- PTSD Checklist score 38 (was 62 at intake)
- Completed imaginal exposure homework 4x this week
- Highest SUDS during homework: 65 (down from 85 initially)
- Less avoidance of trauma reminders - able to watch war movies with family
- Hypervigilance "definitely better" - less startled by loud noises
- Reengaged in social activities - attended friend's BBQ last weekend

Current symptoms still present (but reduced):
- Some intrusive memories, 2-3x/week (were daily)
- Mild hypervigilance in crowds
- Occasional emotional numbing

In vivo exposure progress:
- Completed exposure to VA hospital (previously avoided)
- Planning exposure to crowded mall this week

Sleep: 6 hours continuous (was 3-4 fragmented hours)
Denies suicidal or homicidal ideation.
Denies substance use relapse - sober 14 months.

Chief Complaint: "The medication is helping a lot. I'm actually finishing projects now."

Interval History: 40-year-old male with newly diagnosed ADHD (Combined Type), presenting for 4-week follow-up on stimulant medication. Patient reports significant improvement in attention, organization, and task completion. He describes:

Symptom Improvement on Medication:
- Concentration at work "dramatically better" - able to focus on tasks for 2+ hours
- Less procrastination - completing projects before deadlines
- Better able to follow conversations and retain information
- Reduced impulsivity - thinking before speaking in meetings
- Wife notes he's "more present" and listening better

Medication Experience:
- Taking Adderall XR 20mg every morning as prescribed
- Effect lasts approximately 8-10 hours
- Mild appetite suppression at lunch (eating smaller meals)
- Initial insomnia first week, now sleeping well if dose taken before 8am
- No cardiovascular symptoms (chest pain, palpitations)
- No mood changes, irritability, or euphoria

Current Concerns:
- Wondering if dose needs adjustment for afternoon meetings (effect wears off by 4pm)
- Occasional "crash" feeling around 5pm

Denies misuse, early refills, or diversion.
Denies depression, anxiety, or suicidal ideation.
Denies substance use (was requirement for stimulant treatment).