SOAP Note Example

Substance Abuse Recovery

Client is focused on substance abuse recovery using motivational interviewing.

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 difficulties with substance abuse and its effect on relationships, stating the need to "stay clean."

Objective:
60-minute session focused on motivational interviewing and relapse prevention strategies.

Assessment:
Client demonstrated hope and commitment to recovery.

Plan:
Client's homework includes attending a support group meeting and developing a relapse prevention plan. Next session 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 session with the client focused on his struggle with substance abuse. He mentioned the difficulties of staying sober and the impact on his relationships. He said, "I need to stay clean." We used motivational interviewing and relapse prevention strategies. Client’s homework is to attend a support group meeting and develop a relapse prevention plan. He seemed hopeful and committed to recovery. We’ll meet again next week.

Other Note Formats:

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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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