SOAP Note Example: Overwhelmed by Workload

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 feeling overwhelmed with her workload and experiencing high levels of anxiety, particularly in relation to meeting deadlines. She mentioned she has trouble sleeping and frequently wakes up at night with worries about tasks. Client stated, "I feel like I’m constantly on edge and can’t relax."

Objective:
A 45-minute session was conducted at the clinic. Client's mental status was evidenced by expressions of anxiety and sleep disturbances. Introduced basic mindfulness exercises as an intervention during the session.

Assessment:
Client is demonstrating symptoms of anxiety, which are impacting her sleep quality. Progress includes engaging in goal setting for improving sleep through a bedtime routine and expressing motivation to practice mindfulness techniques.

Plan:
Client's homework is to practice a five-minute mindfulness exercise each day. Scheduled the next session for next week at the same clinic location.

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 had a 45-minute session at the clinic today. She talked about feeling overwhelmed with her workload and said she is often anxious about meeting deadlines. Ummm, client mentioned that she has trouble sleeping and frequently wakes up at night worrying about tasks she needs to complete. She said, "I feel like I’m constantly on edge and can’t relax." We discussed the importance of self-care and established a goal for her to create a bedtime routine to help improve her sleep. We also introduced some basic mindfulness exercises. Client’s homework is to practice a five-minute mindfulness exercise each day. She seemed motivated and interested in trying out the new techniques. Our next session is scheduled for next week.

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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.