SOAP Note Example

Trauma from Medical Procedures

Client is processing trauma related to past medical procedures.

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 reported increased anxiety due to resurfacing memories of a past medical procedure, stating 'I just shut down whenever I think about it' and noting physical symptoms such as tension, accelerated heart rate, and difficulty breathing. Discussed the impact of medical trauma and its potential equivalence to other trauma types.

Objective:
45-minute office session observed. Client appeared anxious but engaged in learning a grounding technique. Practiced a five senses grounding exercise to manage overwhelming feelings associated with traumatic memories.

Assessment:
Client is experiencing symptoms of medical trauma with significant anxiety and physiological responses. The grounding technique was introduced and practiced, which seemed to provide the client with some relief.

Plan:
Client was assigned homework to practice the grounding technique when memories arise. The therapist and client will reconvene next week to evaluate the effectiveness of the technique and consider exploring deeper emotional responses.

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.

We had a 45-minute office session today, and the client came in looking pretty anxious, talking about how memories from a past medical procedure have been coming up more and more lately. They said quote 'I just shut down whenever I think about it' unquote and described how it’s affecting them physically, too—like they get tense, their heart starts racing, and they feel like they can’t breathe. We talked about how medical trauma can sometimes be just as intense as other types of trauma, even though people don’t always recognize it that way.

We spent some time going over a grounding technique that could help them stay present when those memories come up, because they’ve been feeling pretty overwhelmed. I walked them through the five senses grounding exercise—focusing on what they can see, hear, touch, taste, and smell to bring them back to the present. They seemed to relax a bit once we practiced that. Their homework is to try using that technique whenever they feel those memories creeping up, just to see if it helps them stay grounded. By the end of the session, they seemed a little more at ease, like they finally had something concrete to try. We’ll meet again next week to see how it’s going and maybe start digging into some of the deeper emotional stuff after they’ve had a chance to try out the grounding.

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