SOAP Note Final RF2

Client is a {AGE} self-identified [select name="gender" value="female|male|non-binary"] who presents today on HIPAA compliant Google Meet platform as client was attending from their home address. Participants in the session include this writer and [checkbox name="particpants" value="client|client's parent|client's spouse|client's family member(s)"] Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

SUBJECTIVE/CHIEF COMPLAINT:
Client expressed the following about the problem," [text name="problem" default=""]."
The following concerns/updates since last session were addressed, [textarea name="concerns" default ""]

Client continues to report symptoms consistent with {DIAGNOSIS}, including:
[checkbox name="symptoms" value="Depressed mood|Sadness|Anhedonia|Tearful or crying spells|Fatigue/low energy|Negative cognitions|Restlessness|Difficulty sleeping|Trouble falling asleep|Appetite changes|Low motivation|Difficulty with organization|Hyperactivity|Inattention|Task avoidance|Difficulty with task initiation|Difficulty handling transitions|Difficulty persisting on challenging or tedious tasks|Concrete/literal thinking|Difficulty handling ambiguity/uncertainty|Sensory difficulties|Poor academic/work performance|Isolation from others|Loneliness|Low self-esteem|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|Difficulty concentrating|Muscle tension|Feeling on edge|Difficulty controlling worry/excessive worrying|Worry about work/school|Worry about health|Worry about finances|Panic attacks|Fear|Hopelessness|Feelings of worthlessness/inappropriate guilt|Intrusive thoughts|Flashbacks|Dissociation/Depersonalization/Derealization|Avoidance of thoughts/memories of traumatic event|Impulsivity|Obsessions/compulsions|Phobias|Self-harm|Substance abuse|Nightmares|Hypervigilance/Easily startled|Grief|Worry about future of relationship|Low self-confidence|Interpersonal conflicts|Irritability|Emotional instability|Other"][text name ="other" default""]

Focus/themes of session for today was:
[checkbox name="topics" value="----MOOD MANAGEMENT----|Current symptoms/functioning|Symptom management|Management of depressive symptoms|Management of anxiety symptoms|Emotion dysregulation|Distress intolerance|Anger issues|Negative cognitions|----ADHD----|ADHD symptoms|ADHD treatment/medications|Self-esteem|Management of executive dysfunction|
----GENDER/SEXUALITY----|Gender identity|Sexual orientation|Coming out process|Reactions from family/friends/others|----OTHER TOPICS----|Homework/assignment follow up|Goals/treatment plan review|Client history/background|----ATTACHMENT ISSUES---|Adult attachment style issues|Attachment anxiety and avoidance|Adult attachment anxiety|Fear of developing intimate relationships|Fear of interpersonal rejection and/or abandonment|Adult attachment avoidance|Fear of intimacy|Excessive need for self-reliance|Distrust of others|
----RELATIONSHIP DISTRESS----|Relationship dissatisfaction|Conflict/argument with partner|Intimacy concerns|Infidelity/affair concerns|Child custody conflict|Codependency issues|Divorce issues|Trust concerns|Communication problems with partner|Breakup/acute relationship concerns|Abuse/IPV|Relationship trauma|----ADJUSTMENT DISORDER----|Adjustment to stressor(s)|Adjustment to workplace changes|Adjustment to job loss/change|Adjustment to relationship changes|Adjustment to family life changes|Adjustment to a developmental event|----GRIEF/LOSS----|Death of a family member|Death of a friend|Grief reactions|Processing past regrets|Processing grief|Processing a death/loss|----INTERPERSONAL PROBLEMS----|Interpersonal conflict(s)|Conflict with friends|Conflict with family of origin|Conflict with extended family|Conflict within nuclear family|Conflict with partner/spouse|Conflict with coworker(s)|Communication issues|Poor boundary setting|Difficulty saying no to others|Passive behaviors|Aggressive behaviors|----BEHAVIORAL HEALTH ISSUES----|Self-Care activities|Sleep difficulty/concerns|Nutrition/eating habits|Physical activity/exercise|------SUBSTANCE USE ISSUES----|Substance use concerns|Alcohol use concerns|Cannabis use concerns|Tobacco use concerns|Relapse prevention|----TRAUMA----|Family of origin dynamics|Past trauma event|Recent trauma event|Sexual trauma event|Childhood trauma|Past childhood abuse/neglect|----STRESSORS----|Life stressors|Stressor/coping mechanism(s)|Family dysfunction|Work problems|School problems|Bullying|Work-related stress|Negative work environment|Difficulty with work/life balance|Financial issues|Legal issues|Housing issues|Relationship issues|Parenting stress|----MEDICAL & HEALTH ISSUES----|Medical/health concerns|Medication concerns|New diagnosis|Physical pain|----RELIGIOUS ISSUES----|Religious/spiritual concerns|Other"][text name="other" default=""]

Changes in medication: [text name="medication" default=""]

OBJECTIVE/MENTAL STATUS EXAM:
Orientation: [checkbox name="MSE_1" value="Alert and oriented X4|unable to assess due to cognitive impairment"] Time: [checkbox name="time" value= "On time|Late" Appearance: [checkbox name="appearance" value="Clean/Neat|Casual|Desheveled"] Affect: [checkbox name="MSE2" value="Full range|Flat|Blunted|Labile|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inappropriate to mood and thoughts|Restricted in range, mood congruent"] Mood: [checkbox name="mood" value="Euthymic|Depressed|Anxious|Irritable|Elevated|Other"][text name="other2" default=""] 
Speech: [checkbox name="MSE4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|Soft"] Behavior: [checkbox name="MSE_5" value="WNL|Appropriate|Inappropriate"] Thought process: [checkbox name="MSE_6" value="WNL|Logical, linear, goal directed|Circumstantial|Circumstantial but redirectable|Tangential"] Insight/Judgement [checkbox name="insight" value="Good|Fair|Limited|Poor"] A/V Hallucinations: [checkbox name="MSE8" value="No history|Denied A/V hallucinations|Endorsed auditory hallucinations|Denied auditory hallucinations| Denied visual hallucinations|Endorsed visual hallucinations"]

ASSESSMENT:
Safety/Risk Factors
[checkbox name="safety" value="SI/HI denied|Endorsed suicidal ideation|Endorsed passive SI|Endorsed active SI with a method but without plan or intent to Act|Endorsed recent suicide attempt|Endorsed Nonsuicidal Self-Injury|Denied homicidal ideation|No additional risk factors present"]

Symptoms are consistent with:
[checkbox name="diagnosis" value="Anxiety disorders|Trauma and stressor related disorders|Depressive disorders|Adjustment disorders|Neurodevelopmental disorders/ADHD/ASD|Other"] [text name="other" default=""]

Assessments completed and scores: 
[checkbox name="00" value="None"][checkbox name="PHQ" value= "PHQ9"][conditional field="PHQ" condition="(PHQ).is('PHQ9')"][text name="score1" default=""][checkbox name="GAD" value= "GAD7"][/conditional][conditional field="GAD" condition="(assessments).is('GAD7')"][text name="score2" default=""][checkbox name="PCL" value= "PCL5"][/conditional][conditional field="PCL" condition="(assessments).is('PCL5')"][text name="score3" default=""][/conditional][checkbox name="DES_" value= "DES"][conditional field="DES_" condition="(DES_).is('DES')"][text name="score4" default=""][/conditional][checkbox name="SCARED_" value= "SCARED"][conditional field="SCARED_" condition="(SCARED_).is('SCARED')"][text name="score5" default=""][/conditional][checkbox name="ASRS" value= "ASRS1.1"][conditional field="ASRS" condition="(ASRS).is('ASRS1.1')"][text name="score6" default=""][/conditional]

From the client’s report and therapist observation, client is experiencing impairment in the following areas:
Sense of meaning: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s sense of meaning from life.
General wellbeing: [select name="functioning1" value="No|Mild|Moderate|Severe"] disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: [select name="functioning2" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to engage and/or derive satisfaction from social connections. 
Daily tasks: [select name="functioning3" value="No|Mild|Moderate|Severe"] disruption to the client’s ability to perform daily necessary tasks for life. 
Family: [select name="functioning4" value="No|Mild|Moderate|Severe"]  disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: [select name="functioning5" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: [select name="functioning6" value="No|Mild|Moderate|Severe"] disruption to the client’s financial stability. 
Romantic relationships: [select name="functioning7" value="No|Mild|Moderate|Severe"] disruption to the client’s satisfaction from or ability to engage in romantic relationships.

The client displayed the following strengths and capabilities during the session: 
[checkbox name="strengths" value="motivation to progress in treatment|utilization of positive coping techniques|ability to express emotions|ability to receive feedback from therapist|awareness of emotions|awareness and honesty around negative coping techniques|ability to tolerate painful feelings|openness to trying new, positive behaviors|having compassion for self"]
 
INTERVENTIONS:
In sessions interventions provided:
[checkbox name="interventions2" value="----MOOD DISORDER INTERVENTIONS----|Active listening and feedback|Validated and normalized thoughts/emotions|Supportive reflection|Open-ended questions|Socratic questioning|Self-disclosure|Psychoeducation|Rapport building|Clarification|Reframing|Praise and encouragement|Reassurance|Assessment of client history|----ADHD----|Encouraging use of positive self-talk exercises|Exploration of time management skills|Exploration of organizational skills|Exploration of prioritization skills|Encouraging outside reading on ADHD/neurodivergence|Providing education about ADHD/neurodivergence|Identifying strengths/positive qualities|Exploration of social constructs|----COGNITIVE BEHAVIORAL THERAPY----|Introduction to the CBT model|Cognitive challenging|Cognitive restructuring|Identification/modification of dysfunctional assumptions/biases|Identification of distorted automatic thoughts|Reviewing negative thinking patterns|Identifying negative thinking patterns using examples from client's life|Reviewing 'feelings wheel'|Developing alternative thoughts and beliefs|Exploring how thoughts/beliefs influence mood and behaviors|----INTERPERSONAL INTERVENTIONS----|Exploration and education of communication skills to address interpersonal concerns|Education of assertive communication skills|Exploration of interpersonal patterns|Identifying and discussing boundary setting|Assisting client with practicing communication tools|----TREATMENT REVIEW----|Reviewing homework|Reviewing client's treatment plan and discussing progress towards goals|Goal setting|Administration of clinical assessments|Exploration of termination|Planning termination|Reviewing treatment frequency|----GENERAL INTERVENTIONS----|Reviewing family hx/dynamics|Role playing|Modeling|Problem-solving|Identifying/labeling emotions|Processing thoughts and feelings|Identifying negative coping and defense mechanisms|Providing psychoeducation on presenting concerns|Providing resources/literature to review|Identifying barriers to treatment/progress|----STRESS MANAGEMENT/COPING----|Provided psychoeducation on stress management interventions|Stress management intervention: deep breathing|Stress management intervention: PMR|Subjective Unit of Distress (i.e., SUDs)|Mindfulness practices|Grounding techniques|Identifying and planning enjoyable physical activities|Practicing progressive muscle relaxation|Guided imagery|Diaphragmatic breathing|----BEHAVIORAL HEALTH INTERVENTIONS----|Explored self-care strategies|Sleep hygiene interventions|Behavioral activation|Introduced SMART Goals|Identifying positive self affirmations|Identifying and reviewing positive coping skills|Identifying hobbies/values|Discussing benefits/effectiveness of medication|----MOTIVATIONAL INTERVIEWING----|Eliciting change talk|Eliciting alternative behaviors|Identifying pros/cons to change|Assessing readiness for change|----COUPLES & FAMILIES----|Parenting skills:exploring and reviewing effective parenting strategies|Exploration of family dynamics|Facilitating healthy expression of feelings/concerns|Identifying strengths/support system|Exploration of activities to enhance feelings of positive connection|Processing the aftermath of an argument or regrettable incident|Exploration of patterns of closeness and distance in the relationship|Exploration of couple's communication cycles|Observing and providing feedback on couple's communication and interactions|Exploration of family of origin/dynamics|Explored solvable and perpeptual problems|----DBT INTERVENTIONS----|DBT/Emotion regulation skills|DBT/Distress tolerance skills|DBT/Interpersonal effectiveness skills|Exploration of coping patterns|Exploration of emotions|Exploration of relationship patterns|Exploration of maladaptive cyclical patterns|Interpersonal interventions|Interactive feedback/process comments|Mindfulness|----TRAUMA & GRIEF/LOSS----|
Exploration of trauma and impacts on client's life|Exploration of potential reasons for behaviors/symptoms|Exploration of patterns of avoidance|Identifying consequences of avoidance|Providing psychoeducation on role avoidance plays in maintaining PTSD symptoms|Providing psychoeducation on PTSD symptoms|Identifying and processing issues around grief/loss|Exploration of trauma/abuse|Identifying triggers|Identifying alternative behaviors/coping skills that have helped in the past|Exploration and identifying strengths and support system"]
[checkbox name="EMDR" value= "EMDR"][conditional field= "EMDR" condition="(EMDR). is('EMDR')"][checkbox name="phases" value= "Phase 1|Phase 2|Phase 3/Assessment|Phase 4/Desensitization| Phase 5/Installation|Phase 6/Body Scan|Phase 7/Closure|Phase 8/reevaluation|Safe/Calm Place|Future Template|Resource Development and Installation|Container Exercise|Spiral Technique|Recent Event Protocol|Float Back Exercise"][checkbox name= "EMDR2" value= "NC"][text name="NC" default=][checkbox name= "EMDR3" value= "PC"][text name="PC" default=""][checkbox name= "EMDR4" value= "VOC Starting"][conditional field="EMDR4" condition="(EMDR4).is('VOC Starting')"][select name="EMDR5" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR6" value= "VOC Ending"][conditional field="EMDR6" condition="(EMDR6).is('VOC Ending')"][select name="EMDR7" value="select one|1|2|3|4|5|6|7"][/conditional][checkbox name= "EMDR8" value= "SUDS Starting"][conditional field="EMDR8" condition="(EMDR8).is('SUDS Starting')"][select name="EMDR9" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][checkbox name= "EMDR10" value= "SUDS Ending"][conditional field="EMDR10" condition="(EMDR10).is('SUDS Ending')"][select name="EMDR11" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional][/conditional]

The client’s observable reaction to these interventions were: [checkbox name="reactions" value="positive|engaged|motivated| open|resistant|reluctant|negative|hesitant"]

Treatment progress:
Client progress in achieving treatment goals is best assessed as [checkbox name="progress1" value="responding well to interventions|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|an increase in symptoms|a decrease in symptoms|a significant escalation in symptoms|minimal|improving|stable"] as evidenced by client self-report, observed behavior, and level of engagement.

PLAN:
Changes in diagnosis or treatment plan: [text box="changes" value="None"]

Frequency of sessions:
[checkbox name="plan1" value="Weekly individual therapy.|Biweekly individual therapy.|RTC in 1-2 weeks.|RTC in 2 weeks to assess relationship functioning and review progress.|RTC in 1 month to assess functioning/progress.|Client will contact Provider to schedule next session.|Provider will contact Client to schedule next session."]

Plan for next session is to review [checkbox name="checkon" value="homework/outside assignment|recent stressors/emotional experiences|symptom intensity/frequency|goal achievement/outcomes"]
Therapist will also follow up on [checkbox name="followup" value="activity scheduling|reframing/identifying cognitive distortions|mindfulness exercises|self care|spending time with others|prioritization/time management|setting/maintaining boundaries|utilization of communication tools|utilization of coping strategies|journaling|modifying eating/exercise habits|other"][text name="other" default=""]

Homework: Ct agreed to [text name="homework" default=""].

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to: [select name="neccessity" value="Address symptoms/achieve symptomatic relief.|Improve functioning in one or more life domains.|Maintain progress/prevent decompensation.|Prevent higher level-of-care/avoid hospitalization."]
Client is a {AGE} self-identified who presents today on HIPAA compliant Google Meet platform as client was attending from their home address. Participants in the session include this writer and Client is aware of how the telehealth appointment will proceed; agreement to a communication back up plan if connection fails; client is aware of the risks and limitations of telehealth appointment; suitable electronic connection has been established; client is satisfied with the level of privacy of current environment; client’s identity has been established; client fits within therapist’s scope for telehealth.

SUBJECTIVE/CHIEF COMPLAINT:
Client expressed the following about the problem," ."
The following concerns/updates since last session were addressed,


Client continues to report symptoms consistent with {DIAGNOSIS}, including:


Focus/themes of session for today was:


Changes in medication:

OBJECTIVE/MENTAL STATUS EXAM:
Orientation: Time: Affect: Mood:
Speech: Behavior: Thought process: Insight/Judgement A/V Hallucinations:

ASSESSMENT:
Safety/Risk Factors


Symptoms are consistent with:


Assessments completed and scores:


From the client’s report and therapist observation, client is experiencing impairment in the following areas:
Sense of meaning: disruption to the client’s sense of meaning from life.
General wellbeing: disruption to the client’s general sense of wellbeing and mental health in a way that the client can provide for self and dependent others.
Social/friendships: disruption to the client’s ability to engage and/or derive satisfaction from social connections.
Daily tasks: disruption to the client’s ability to perform daily necessary tasks for life.
Family: disruption to the client’s satisfaction and stability in family life and connection.
Work/Academic: disruption to the client’s satisfaction or productivity in the client’s function at work/school.
Economic: disruption to the client’s financial stability.
Romantic relationships: disruption to the client’s satisfaction from or ability to engage in romantic relationships.

The client displayed the following strengths and capabilities during the session:


INTERVENTIONS:
In sessions interventions provided:



The client’s observable reaction to these interventions were:

Treatment progress:
Client progress in achieving treatment goals is best assessed as as evidenced by client self-report, observed behavior, and level of engagement.

PLAN:
Changes in diagnosis or treatment plan:

Frequency of sessions:


Plan for next session is to review
Therapist will also follow up on

Homework: Ct agreed to .

The service provided is medically necessary and appropriate for the treatment of the diagnosed condition to:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.74, 79 form elements, 395 boilerplate words, 17 text boxes, 1 text areas, 36 checkboxes, 14 drop downs, 11 conditionals, 465 total clicks
Questions/General site feedback · Help Ticket

3 responses to “SOAP Note Final RF2”

  1. Catchy Title: halp
    Type of request: problem using an existing form
    What is the address of the page(s) that is/are causing problems: https://www.soapnote.org/social-work/soap-note-final-rf2/
    Any other details that might help: Under interventions, towards the end of the list where it says VOC starting, VOC ending, SUDs starting, SUDs ending.. I don’t want the drop downs to show unless the box is checked. I know it’ll be some kind of conditional formatting, but I can’t figure it out. Can someone problem solve/help with this? Thanks!

    • SOAPnote says:

      Hi – this works for that:

      [checkbox name= "EMDR4" value= "VOC Starting"][conditional field="EMDR4" condition="(EMDR4).is('VOC Starting')"][select name="EMDR5" value="select one|1|2|3|4|5|6|7"][/conditional]
      [checkbox name= "EMDR6" value= "VOC Ending"][conditional field="EMDR6" condition="(EMDR6).is('VOC Ending')"][select name="EMDR7" value="select one|1|2|3|4|5|6|7"][/conditional]
      [checkbox name= "EMDR8" value= "SUDS Starting"][conditional field="EMDR8" condition="(EMDR8).is('SUDS Starting')"][select name="EMDR9" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional]
      [checkbox name= "EMDR10" value= "SUDS Ending"][conditional field="EMDR10" condition="(EMDR10).is('SUDS Ending')"][select name="EMDR11" value="select one|0|1|2|3|4|5|6|7|8|9|10"][/conditional]

      • perfect!!!! that helped me tremendously in figuring out another aspect of the note.. i was able to use the same code to make it to where when i click one of the assessment names under assessments used, it brings up a text box for me to enter the score! yay! thanks again!

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