SOAP Progress Note UPDATED

Met with patient. Patient reports doing [checkbox name="concerns" value="okay|better than last week|worse compared to last week|not so good"].


Patient reports experiencing symptoms of [checkbox name="variable1" value="anxiety|depressed mood|sadness|loss of interest in pleasurable activities|tearful or crying spells|fatigue/low energy|difficulty sleeping|trouble falling asleep|appetite changes|difficulty concentrating|low motivation|poor academic/work performance|isolation from others|loneliness|low self-esteem|suicidal ideation|anxiety of social situations|concerns of negative evaluation by others|fear of embarrassing self|panic/abrupt surge of intense fear/intense discomfort|worry about having future panic symptoms/attacks|muscle tension|difficulty controlling worry/excessive worrying|worry about job responsibilities|worry about health|worry about finances|panic attacks|fear|hopelessness|impulsivity|hypervigilance|grief|worry about future of relationship|low self-confidence|interpersonal conflicts|irritability|emotional instability"]. 


Patient discusses [checkbox name="variable4" value="symptom management|management of depression symptoms|management of anxiety symptoms|self-esteem|ADHD|friendships|childhood/family of origin|emotion dysregulation|anger issues|distress intolerance|an adjustment to a stressor(s)|grief/loss|relationship distress|relationship dissatisfaction|relationship argument or regrettable incident with partner|relationship intimacy concerns|interpersonal ineffectiveness/conflict|boundary setting|a conflict with peers|a conflict with family|a conflict with coworker(s)|self-care/hygiene issues|sleeping issues|physical activity/exercise|substance use concerns|alcohol use concerns|cannabis use concerns|nicotine use concerns|trauma|stressor(s)/coping mechanism(s)|familial relationship distress|employment issues|financial issues|legal issues|housing issues|parenting stress|medical/health concerns|medication concerns|religious/spiritual concerns|other"][text name="variable5" default=""].


Patient displays [checkbox name="variable16" value="awareness of emotions|motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions/feelings|willingness to be vulnerable and ask for help from others at critical times|awareness and honesty around negative coping techniques|the ability to tolerate painful or uncomfortable feelings|openness to trying new, positive behaviors|seeking positive relationships|having compassion for self"].


[checkbox name="variable2" value="Patient denies current prescription of medication(s).|Patient reports no changes to prescribed medication(s).|Patient reports changes to prescribed medication(s).|Patient notes"][text name="variable3" default=" "]


Patient participates in assessment for safety/risk factors. Patient endorses [checkbox name="variable7" value="no current suicide or homicide ideation|current suicide/homicide ideation|past suicide/homicide ideation|current suicide/homicide ideation with means but without plan or intent to act|past suicide/homicide attempt|recent suicide/homicide attempt|non-suicidal self-injury"].

[checkbox name="cb12" value="Patient will identify treatment plan goals.|Patient begins to develop treatment plan goals.|Patient reviews/makes changes to treatment plan goals.|Patient will identify triggers that impact mental health symptoms.|Therapist builds therapeutic rapport with patient."]


Therapist [checkbox name="variable17" value="reviewed of homework|reviewed of patient's treatment plan and discussion of progress towards goals|provided psychological assessments|assisted with boundary setting|provided active and empathetic listening toward the patient's thoughts and feelings|engaged using open-ended questions|stated normalization/validation of thoughts and feelings|conducted therapeutic rapport building|provided encouragement and reassurance|reviewed family history/dynamics|provided role-play exercises|assisted patient in problem-solving|processed patient's thoughts and feelings|identified negative coping mechanisms|provided psychoeducation about mindfulness and meditation|provided relaxation skills|provided psychoeducation|identified and challenged cognitive distortions|practiced cognitive restructuring|reviewed self-care activities|stated positive affirmations|identified and/or reviewed positive coping skills|reviewed and practiced effective communication skills and assertiveness techniques|elicited change talk|explored and reviewed effective parenting strategies|processed the aftermath of an argument or incident|explored patterns of closeness and distance in relationships|explored couple's communication cycles|observed and provided feedback on couple's communication and interactions|provided DBT/emotion regulation skills|provided DBT/distress tolerance skills|provided DBT/interpersonal effectiveness skills|provided CBT approaches|provided psychoeducation on improvement of sleeping habits|created a behavioral activation list with patient|explored trauma and impacts on patient's life|explored patterns of conflict|explored potential reasons for behaviors/symptoms|identified and processed issues around grief/loss|identified triggers|identified alternative behaviors/coping skills that have helped in the past|identified and explored strengths and/or support system|utilized person-centered modalities|utilized EFT modalities|utilized ACT modalities|utilized motivational interviewing (MI) approaches"].


Therapist will [checkbox name="cb14" value="follow up with patient in 1 week to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with patient in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with patient in 1-2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with patient in 2 weeks to assess mood/functioning, and implementation of treatment plan goal(s)|follow up with patient in 1 month to assess mood/functioning, and determine need for termination|begin termination process with patient|Patient will contact therapist to schedule next session.|Therapist will contact patient to schedule next session."]. Patient agreed to this plan.