SOAP note – new

Present in session: [text name="variable_1" default=""]
Setting: [select name="setting" value="face to face|telehealth|phone call"]

Subjective: [textarea name="subj" default=""]

Objective:
Mental Status Exam
Appearance
Grooming: [select name="grooming" value="Within norm|Notable"]
Motor Activity: [select name="motor" value="Within norm|Notable"]
Coordination/Gait: [select name="coord" value="Within norm|Notable"]
Notes on appearance: [text name="noteapp" default="Nothing unusual to note"]
Relatedness: [checkbox name="relate" value="Cooperative|Friendly|Relaxed|Good eye contact|Hostile|Guarded|Seductive|Poor eye contact"]
Speech/Language
Receptive: [select name="recep" value="Within norm|Notable"]
Expressive: [select name="expre" value="Within norm|Notable"] [checkbox name="speech" value="Quiet|Loud|Slow|Clutter/Stutter|Rapid|Pressured"]
Affect/Mood
Affect: [checkbox name="affect" value="Expressive|Good range|Flat|Constricted|Angry|Mood-incongruent|Anxious|Sad|Labile|Inappropriate to situation"]
Mood: [checkbox name="mood" value="Euthymic|Elevated|Depressed|Angry"]
Thought Process: [checkbox name="thought" value="Goal directed|Logical|Abstract reasoning|Tangential|Circumstantial|Magical|Concrete|Flight of ideas|Sloe|Rapid|Loose"]
Thought Content: [checkbox name="thoughtcon" value="Appropriate|Hallucinations|Delusions|Depressive ideation|Suicidality|Aggressiveness|Homicidality"]
Memory
Short term: [select name="stmem" value="Intact|Impaired"]
Long term: [select name="ltmem" value="Intact|Impaired"]
Attention/Concentration: [select name="attn" value="Within norm|Notable"]
Alertness/Orientation: [checkbox name="alert" value="Alert|Orientated|Lethargic|Hypervigilant|Disoriented"]
Judgement/Planning
Judgement: [select name="judge" value="Within norm|Notable"]
Impulse control: [select name="impulse" value="Within norm|Notable"]
Insight: [select name="impulse" value="Within norm|Notable"]
Comments: [textarea name="msecomm" default=""]
Engagement in session: [checkbox name="engage" value="cooperative|willing|reluctant|distracted|evasive|guarded|passive|withdrawn|hostile|relaxed|open"]

Risk Assessment
Harm to self or others: [select name="harm" value="No|Yes"]
Specific plan: [select name="plan" value="No|Yes"]
Previous risk-taking/suicidal behavior: [select name="prev" value="No|Yes"]
Current stressors: [select name="stressors" value="No|Yes"]
Significant distress: [select name="distress" value="No|Yes"]
External supports: [select name="support" value="Yes|No"]
[checkbox name="exsup" value="Family members|GP|Friends|Collegues|Partner|MH worker"]
Protective factors: [checkbox name="protect" value=" social support|family|future-oriented|medication compliance|therapy compliance"]
Risk: [select name="risk" value="Low|Moderate|High|Emergency"]

Assessment/Intervention:
Progress: [select name="progress" value="actively making progress|making some progress|planning|no observable progress|not engaged in session|not engaged in therapy"]
Intervention:
Client update, [checkbox name="update" value="validating client experience|relieving distress|processed thoughts and feelings since last session|psychoeducation"]
CBT: [select name="cbt" value="Introducing CBT to client|Goal setting|Identify unhelpful thinking|Challenging unhelpful thinking|Cognitive restructuring|Reframing|Exposure therapy|Guided discovery|Relaxation and stress reduction techniques|Role playing|Behaviour activation|Homework|N/A"]
ACT: [select name="act" value="Values - identifying and clarifying|Experiential avoidance|Breathing/grounding exercises|Creative hopelessness|Cognitive defusion from unhelpful thoughts|Mindfulness/contact with the present moment|Self-compassion|N/A"]
DBT: [select name="dbt" value="distress tolerance|chain analysis|interpersonal effectiveness|mindfulness|N/A"]
Other: [text name="INTOTH" default=""]

Assessment: [checkbox name="assessment" value="initial assessment conducted|DASS-21|K10|ABAS-3|Vinelands 3|WHOQOL|WHODAS|Suicide risk assessment|no assessment conducted during the session"]
Other: [text name="assother" default=""]
Results: [textarea name="results" default=""]

Plan
[checkbox name="plan" value="homework|continue sessions|future session booked on:|close due to non-compliance/engagement|intervention complete - client check in session made|intervention complete - close client file"]
Next session: [select name="next" value="Introducing CBT to client|Goal setting|Identify unhelpful thinking|Challenging unhelpful thinking|Cognitive restructuring|Reframing|Exposure therapy|Guided discovery|Relaxation and stress reduction techniques|Role playing|Behaviour activation|Homework|Values - identifying and clarifying|Experiential avoidance|Breathing/grounding exercises|Creative hopelessness|Cognitive defusion from unhelpful thoughts|Mindfulness/contact with the present moment|Self-compassion|distress tolerance|chain analysis|interpersonal effectiveness|mindfulness|N/A"]
Present in session:
Setting:

Subjective:


Objective:
Mental Status Exam
Appearance
Grooming:
Motor Activity:
Coordination/Gait:
Notes on appearance:
Relatedness:
Speech/Language
Receptive:
Expressive:
Affect/Mood
Affect:
Mood:
Thought Process:
Thought Content:
Memory
Short term:
Long term:
Attention/Concentration:
Alertness/Orientation:
Judgement/Planning
Judgement:
Impulse control:
Insight:
Comments:

Engagement in session:

Risk Assessment
Harm to self or others:
Specific plan:
Previous risk-taking/suicidal behavior:
Current stressors:
Significant distress:
External supports:

Protective factors:
Risk:

Assessment/Intervention:
Progress:
Intervention:
Client update,
CBT:
ACT:
DBT:
Other:

Assessment:
Other:
Results:


Plan

Next session:

Result - Copy and paste this output:

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