SOAP Note Example

Caregiver Stress

Client feels overwhelmed by caregiving responsibilities and is learning self-care strategies.

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 expressed feeling overwhelmed with her responsibilities as a caregiver for her elderly mother and reported stress and exhaustion. Client stated, "I feel like I’m losing myself in all of this," indicating a loss of personal identity amidst caregiving duties.

Objective:
The 30-minute session took place in the therapist's office. The therapist observed that the client seemed relieved and eager after discussing self-care strategies.

Assessment:
Client is experiencing caregiver stress which is impacting her well-being. Discussed strategies for self-care appear to have been positively received.

Plan:
Client’s homework is to identify a preferred activity and schedule time for it daily. Therapist and client to follow up on the implementation of self-care strategies in the next session scheduled for next week.

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 met with therapist for a 30-minute session at the office. She talked about feeling overwhelmed by her role as a caregiver for her elderly mother. Ummm, she said she’s been feeling stressed and exhausted and doesn’t have much time for herself. She said, "I feel like I’m losing myself in all of this." We discussed the importance of self-care and setting boundaries. We explored some practical ways for her to take breaks and delegate some responsibilities. Client’s homework is to identify one activity she enjoys and schedule time for it each day. She seemed relieved to have a plan and eager to implement it. We’ll follow up in our next session next week.

Other Note Formats:

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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.

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