SOAP Note Example: Seasonal Affective 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 experiencing symptoms of seasonal affective disorder (SAD) as the days have grown shorter. They described feeling increasingly down, with low energy and motivation, stating, "I feel like I'm just dragging myself out of bed." Client noted difficulty completing daily tasks and mentioned a decrease in social interactions, as they tend to retreat into isolation during this time of year.

Objective:
60-minute virtual session. Client appeared low in energy and discussed the physical and emotional effects of winter, particularly the lack of sunlight and its impact on their mood.

Assessment:
Client is experiencing symptoms consistent with SAD, including low energy, decreased motivation, and social withdrawal. They engaged in discussions about potential strategies to address these symptoms and appeared open to trying suggested interventions, though expressed some uncertainty about implementation.

Plan:
Client will attempt to integrate more sunlight into their daily routine by spending at least 20 minutes outdoors and will consider light therapy as a potential tool. Client was encouraged to begin with small steps, such as short daily walks, to incorporate exercise into their routine. Progress on these adjustments will be reviewed in the next session, which is scheduled for next week.

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 60-minute virtual session focused on the client’s experience with seasonal affective disorder (SAD). As the days grew shorter, they have started to feel increasingly down, with low energy and motivation. They said, "I feel like I'm just dragging myself out of bed," describing how it’s becoming harder to get through daily tasks. We discussed the physical effects of winter, particularly the lack of sunlight, and how this can exacerbate feelings of depression and lethargy. We also talked about how their mental health has been impacted by a decrease in social interactions, as they tend to retreat into isolation during this time of year.

I suggested that they try to integrate more sunlight into their daily routine by spending at least 20 minutes outdoors each day, even if the weather isn’t ideal. We also discussed the possibility of using light therapy to help manage their symptoms. The client seemed willing to try these strategies but expressed uncertainty about how to fit them into their routine. We also discussed the importance of exercise in combating the lethargy of SAD, and I encouraged them to start with something simple like short daily walks. Client agreed to try these steps and track their progress. We’ll check in next week to see how they’re doing with these adjustments.

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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.