SOAP Note Example: Eating Disorder

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 reported struggles with binge eating and body image. She stated, "I can’t control myself around food." Client showed engagement and curiosity by asking questions about therapeutic techniques.

Objective:
Client attended a 55-minute session at the clinic. During the session, dialectical behavior therapy (DBT) techniques were employed, focusing on mindfulness and emotional regulation.

Assessment:
Client appears to be making progress with DBT techniques, showing understanding and interest. She continues to struggle with binge eating and body image, which are consistent with the presenting problems.

Plan:
Client's homework is to maintain a food and mood diary to identify triggers. The next session is scheduled for two weeks from today at the clinic.

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 55-minute session at the clinic today. She talked about her struggles with binge eating and body image. She said, "I can’t control myself around food." We explored her relationship with food using dialectical behavior therapy (DBT) techniques, focusing on mindfulness and emotional regulation. Client’s homework is to keep a food and mood diary to identify triggers. She was engaged and asked questions about the techniques. Our next session is in two weeks.

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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.