SOAP Note Example

Chronic Illness and Mental Health

Client is struggling with the emotional toll of managing a chronic illness and its impact on their mental health.

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 by the management of their chronic illness, stating 'It’s like my illness controls every part of my life.' They reported increased physical symptoms leading to mental health strain, feeling disconnected from previously enjoyed activities, and negative impacts on work and social life.

Objective:
50-minute session held at the office. Client appeared exhausted and presented with a low mood. Engaged in a mindfulness exercise to address emotional and physical stress.

Assessment:
Client is experiencing significant stress related to chronic illness management, affecting both physical and mental health. Demonstrated initial hesitation but later found the mindfulness technique to be grounding.

Plan:
Assigned daily practice of mindfulness exercises with the intention to observe changes in emotional state. Scheduled to reconvene next week to evaluate client's progress and potential adjustments to the intervention strategy.

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.

We had a 50-minute session today at the office. Client came in looking pretty exhausted and was really down about how hard it’s been managing their chronic illness lately. They said quote 'It’s like my illness controls every part of my life' unquote. They talked about how the physical symptoms have been draining, and it’s starting to affect their mental health, too. They mentioned feeling disconnected from things they used to enjoy because they just don’t have the energy anymore, and it’s also affecting their work and social life, which has them feeling even more stressed.

We spent some time talking about the emotional toll of chronic illness and how it’s okay to feel frustrated about how much it impacts daily life. We also discussed how important it is to find small things they can control, even when the illness feels overwhelming. I introduced some mindfulness techniques that could help them manage the emotional and physical stress of their condition. They seemed a little hesitant at first, but after we went through a short mindfulness exercise together, they said it made them feel a bit more grounded. Their homework is to practice one mindfulness exercise each day, even if it’s just for a few minutes, and to note how they feel afterward.

By the end of the session, they seemed a little more hopeful, like they finally had a way to cope with some of the emotional burden. We’ll meet again next week to see how they’re managing and if we need to adjust the approach.

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