SOAP Note Example

Pregnancy Stress and Teen Dating

Client is dealing with pregnancy stress while also navigating their teenage kid starting to date.

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 due to pregnancy and the associated emotional fluctuations. They reported anxiety about the baby's health and the impending life changes. Additionally, the client is concerned about their teenage daughter's new dating life, stating 'Everything just feels so hard right now' and 'I’m just so worried, I don’t know if she’s ready for this'.

Objective:
The session lasted 50 minutes and took place in the therapist's office. The client appeared worn out upon arrival. The therapist observed the client's anxious presentation and provided interventions focusing on managing controllable aspects of their situation, such as planning for the birth and discussing boundaries with their daughter.

Assessment:
The client is experiencing significant stress related to their pregnancy and their daughter's dating. They responded to the session by engaging in the discussion about actionable steps they can take, which suggests a readiness to manage their concerns.

Plan:
The client was assigned homework to have a conversation with their daughter about healthy relationships and to write down their pregnancy-related concerns. The plan is to address these concerns in the next session. A follow-up appointment is scheduled for next week to continue the treatment plan.

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.

Today’s session was 50 minutes, in-office. Client came in looking pretty worn out, and right away they started talking about how overwhelmed they’ve been. They’re pregnant and said quote 'Everything just feels so hard right now' unquote. They’ve been dealing with all the emotional ups and downs of pregnancy—feeling really anxious about the baby’s health and how things will change once the baby’s born. On top of that, their teenage daughter has just started dating, and it’s been adding to the stress. Client said quote 'I’m just so worried, I don’t know if she’s ready for this' unquote.

We talked about how it’s normal to feel overwhelmed with so many big life changes happening at once. I suggested focusing on what they can control, like creating a birth plan and having open conversations with their daughter about healthy relationships. We spent some time discussing boundaries they could set with their daughter, to keep her safe but also give her some room to grow. Their homework is to have that conversation with their daughter this week and to write down some of their biggest concerns about the pregnancy so we can tackle them one by one. They seemed a little more grounded by the end. We’ll meet again next week.

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