SOAP psychology

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

SUBJECTIVE:
[textarea name="subjective" default=""]

OBJECTIVE:
Engagement in session: [checkbox name="engagement" value="cooperative|willing|reluctant|distracted|evasive|guarded|passive|withdrawn|hostile|relaxed|open"]
Mental Status Examination (MSE)
Appearance:
Weight: [select name="weight" value="normal|overweight|obese|underweight|emaciated"]
Dress: [select name="dress" value="casual|immaculate|neat|business|fashionable|bizarre|inappropriate|dirty|stained|disheveled"]
Hygiene: [select name="hygiene" value="good|poor"]
Speech: [checkbox name="speech" value="normal|slow|tangential|pressured|impoverished|slurred|loud|soft|other"]
Eye contact: [checkbox name="eye" value="appropriate|decreased|intense|avoidant|other:"]
Body posture: [checkbox name="body" value="relaxed|tense|slouched|standing|pacing|restless"]
Motor activity: [checkbox name="motor" value="normal|decreased activity|restlessness|tension|agitation"]
Affect: [checkbox name="affect" value="normal|restricted|flat|blunted|labile|broad|reactive|elated|euphoric|anxious|congruent to mood and content of speech|incongruent to mood and content of speech|other"]
Mood: [checkbox name="mood" value="euthymic|anxious|angry|depressed|euphoric|irritable|other"]
Oriented [checkbox name="orient" value="x 3; time, place, person|to place|to person|to time|to object|none"]
Memory impairment: [checkbox name="memory" value="none observed|short-term|long-term|other"]
Thought process: [checkbox name="thoughtpro" value="linear, logical and goal oriented|Associations, eg. how ideas fit together, including rate and flow|poverty of thought; few thoughts|blocking – showed an inability to form thoughts|racing thoughts, flight of ideas; rapid thoughts|loose associations – disconnected thoughts|circumstantiality – lots of extra details but able to get to point|tangentiality; connections between thoughts were apparent, but question were never answered"]
Thought content: [checkbox name="thoughtcon" value="appropriate, with no psychosis, hallucinations, or suicidal or homicidal ideation|delusions – fixed, false beliefs|ideas (or delusions) of reference: voiced belief that unimportant event was related specifically to self|thought insertion or withdrawal; believed that thoughts are being taken out of or put into head|thought broadcasting – belief that others can hear thoughts|Obsessions – distracting, persistent thoughts|compulsions; described irresistible urges to perform meaningless tasks|phobias – client noted irrational fears of specific things"]
Attention: [checkbox name="attention" value="normal|distracted|other"]
Hallucinations: [checkbox name="hall" value="none|auditory|visual|olfactory|tactile (sensory)|other"]
Suicidality: [checkbox name="suicide" value="none|ideation|plan|intent|self-harm"]
Homicidality: [checkbox name="homicide" value="none|agressive|intent|plan"]
Delusions: [checkbox name="delusions" value="none|grandiose|paranoid|religious|other"]
Behaviour: [checkbox name="behavior" value="cooperative|guarded|hyperactive|agitated|paranoid|aggressive|bizarre|withdrawn|other"]
Insight: [checkbox name="insight" value="good|fair|poor"]
Judgement: [checkbox name="judge" value="good|fair|poor"]

Risk for Suicide or Self-harm: [checkbox name="suiself" value="none identified|in distress|history of self-harm|history of suicide ideation|history of previous suicide attempt(s)|denies suicide ideation/harm ideation|denies intent|denies plan|denies means|endorses passive suicide ideation/harm ideation|endorses active suicide ideation/harm ideation|endorses plan|endorses intent|endorses means|self-harm:passive|self-harm:active"]
Protective factors: [checkbox name="protect" value="social support|family|future-oriented|medication compliance|therapy compliance|Other protective factor(s)|N/A"]
Risk Assessment: [select name="riskax" value="low|medium|high"]

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:
1. [select name="variable_1" value="discussed consent and confidentiality|building rapport|client update|processed thoughts and feelings since last session|psychoeducation|validated and normalised experience|confidence building|self-esteem building|relationship building|discussed sleep hygiene|safety planning|goal setting|CBT interventions|behaviour activation|progressive muscle relaxation|cognitive restructuring|reframing|exposure therapy|unravelling cognitive distortions|mindfulness|relaxed breathing|relaxation and stress reduction techniques|behavioural experiments|behaviour activation (eg. scheduling pleasant activities)|emotion regulation|identifying triggers|ACT interventions|cost of avoidance|defusion|values - identifying and clarifying|hooking/unhooking thoughts|dropping anchor|informal mindfulness|DBT interventions|distress tolerance|chain analysis|interpersonal effectiveness|cognitive distortions|mindfulness|Solution focussed therapy"]
2. [select name="variable_2" value="discussed consent and confidentiality|building rapport|client update|processed thoughts and feelings since last session|psychoeducation|validated and normalised experience|confidence building|self-esteem building|relationship building|discussed sleep hygiene|safety planning|goal setting|CBT interventions|behaviour activation|progressive muscle relaxation|cognitive restructuring|reframing|exposure therapy|unravelling cognitive distortions|mindfulness|relaxed breathing|relaxation and stress reduction techniques|behavioural experiments|behaviour activation (eg. scheduling pleasant activities)|emotion regulation|identifying triggers|ACT interventions|cost of avoidance|defusion|values - identifying and clarifying|hooking/unhooking thoughts|dropping anchor|informal mindfulness|DBT interventions|distress tolerance|chain analysis|interpersonal effectiveness|cognitive distortions|mindfulness|Solution focussed therapy"]
3. [select name="variable_3" value="discussed consent and confidentiality|building rapport|client update|processed thoughts and feelings since last session|psychoeducation|validated and normalised experience|confidence building|self-esteem building|relationship building|discussed sleep hygiene|safety planning|goal setting|CBT interventions|behaviour activation|progressive muscle relaxation|cognitive restructuring|reframing|exposure therapy|unravelling cognitive distortions|mindfulness|relaxed breathing|relaxation and stress reduction techniques|behavioural experiments|behaviour activation (eg. scheduling pleasant activities)|emotion regulation|identifying triggers|ACT interventions|cost of avoidance|defusion|values - identifying and clarifying|hooking/unhooking thoughts|dropping anchor|informal mindfulness|DBT interventions|distress tolerance|chain analysis|interpersonal effectiveness|cognitive distortions|mindfulness|Solution focussed therapy"]
Other: [text name="other" 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="continue to build rapport|process thoughts and feelings|psychoeducation|confidence building|self-esteem building|relationship building|sleep hygiene|safety planning|goal setting|CBT interventions|behaviour activation|progressive muscle relaxation|cognitive restructuring|reframing|exposure therapy|unravelling cognitive distortions|mindfulness|relaxed breathing|relaxation and stress reduction techniques|behavioural experiments|behaviour activation (eg. scheduling pleasant activities)|emotion regulation|identifying triggers|ACT interventions|cost of avoidance|defusion|values - identifying and clarifying|hooking/unhooking thoughts|dropping anchor|informal mindfulness|DBT interventions|distress tolerance|chain analysis|interpersonal effectiveness|cognitive distortions|mindfulness|Solution focussed therapy"]