1. Progress Note Examples
  2. Anxiety Diagnosis
  3. SOAP Note Example

SOAP Note Example

Anxiety Diagnosis

Client has been diagnosed with generalized anxiety disorder and is learning coping techniques.

Generated SOAP Note:

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Subjective:
Client attended the session to discuss her recent generalized anxiety disorder diagnosis and associated feelings of uncertainty about the future. She reported frequent worry and a constant sensation of being on edge. Client stated, "I just can’t seem to stop my mind from racing all the time."

Objective:
The 45-minute session took place at the clinic. Client's mental status was consistent with someone experiencing generalized anxiety disorder. Cognitive-behavioral techniques were introduced to assist in managing negative thoughts. Client was engaged and inquired about how to apply these techniques.

Assessment:
Client is making progress in understanding her anxiety and identifying triggers. Her ability to articulate worries and engage with therapeutic techniques is promising for her treatment trajectory.

Plan:
Client was assigned the homework of maintaining a thought diary to record anxiety triggers. The next session is scheduled for two weeks from today, with a focus on reviewing the thought diary and further cognitive-behavioral training.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

Client attended a 45-minute session today at the clinic. She discussed her recent diagnosis of generalized anxiety disorder and her feelings of uncertainty about the future. Ummm, she said she often worries about things that might happen and feels like she’s always on edge. She said, "I just can’t seem to stop my mind from racing all the time." We talked about understanding anxiety and identifying triggers. We introduced cognitive-behavioral techniques to challenge negative thoughts. Client’s homework is to keep a thought diary and note situations that trigger her anxiety. She was engaged and asked questions about the techniques. Our next session is in two weeks.

Other Note Formats:

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BIRP Note Example DAP Note Example PIRP Note Example SIMPLE Note Example

More About SOAP Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about SOAP notes.

More Examples Overview Templates Cheat Sheet

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