SOAP Note Example

Risk of Berries

Client is experiencing heightened anxiety due to berries and the increased risk of exposure.

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 growing anxiety around their allergy to berries, stating, "It feels like berries are everywhere right now, and I’m constantly on edge." They described how the summer season brings frequent exposure to berries at social events, leading to avoidance of such gatherings to reduce risk. Client reported that even seeing someone eat berries nearby triggers anxiety and shared concerns about ending up in the ICU or ER. They expressed frustration over others not understanding the severity of their allergy, contributing to feelings of isolation and fear.

Objective:
60-minute telehealth session. Client appeared engaged and openly discussed their concerns. Anxiety centered around food safety and social interactions was evident. Therapist validated client’s experiences and explored emotional and practical aspects of their anxiety. Interventions included reframing thoughts about self-advocacy, discussing strategies for boundary-setting, and encouraging preparedness for social events.

Assessment:
Client continues to experience significant anxiety related to their berry allergy, which impacts their ability to attend social events and feel safe in public spaces. Their concerns align with treatment goals of reducing avoidance behaviors and increasing self-advocacy. Client responded positively to reframing their feelings of embarrassment as setting important boundaries for their health. Progress is evident in their willingness to identify an upcoming event to practice these strategies.

Plan:
Client will prepare for an upcoming event by discussing their allergy with the host and planning how to manage food-related anxiety. Homework includes creating a mental script for self-advocacy and practicing boundary-setting. Therapist will check in during the next session to review their experience and emotional response. Continuation of treatment will focus on reducing anxiety and building confidence in navigating social situations.

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, and then Quill would generate a note similar to the one above.

In today’s 60-minute telehealth session, the client talked about their growing anxiety around their allergy to berries. They said, "It feels like berries are everywhere right now, and I’m constantly on edge," describing how the summer season brings frequent exposure to berries at picnics, potlucks, and casual gatherings. The client shared that even seeing someone eat berries nearby can trigger a spike in anxiety, and they often avoid social events altogether to reduce the risk. They kept saying how they don't want to end up in the ICU or the ER. They expressed frustration that others don’t always understand the severity of their allergy, which adds to feelings of isolation and fear.

We explored how their anxiety is rooted not just in the physical risk, but in the unpredictability of others' actions and environments they can’t control. I validated the seriousness of their allergy and the emotional toll it takes to constantly assess food safety in public spaces. We discussed strategies for self-advocacy, including clearly communicating their needs ahead of events and carrying emergency medication at all times. I also encouraged them to create a mental script to use when explaining their allergy to others, so they feel more prepared and less reactive.

Client admitted they often feel embarrassed or like a burden when speaking up about their allergy. We reframed this as an important boundary that protects their health and wellbeing. I suggested they identify one upcoming event where they feel safe enough to attend and practice setting boundaries around food. Their homework is to prepare for that event by talking to the host and planning how they’ll handle food-related anxiety. We’ll check in next session to see how it went and how they felt emotionally afterward.

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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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