Clinical SOAP Note
Session Details
Client Legal Name
*
MRN
Date of Service
*
Session Start Time
Session End Time
Session Duration
Modality
In-person
Telehealth
Service Type
Select...
Outpatient Therapy (90834/7)
IIH (H2021)
MH Skill-Building (H2014)
Case Management (T1016)
Psych Eval (90791)
Other
Location of Service
S:
Subjective
Client / Guardian Report
Reported Progress on Goals
O:
Objective
Mental Status Exam (MSE)
Appearance
Well-groomed
Casual
Disheveled
Attitude
Cooperative
Guarded
Hostile
Mood
Euthymic
Depressed
Anxious
Irritable
Affect
Congruent
Blunted
Labile
Flat
Speech
Normal rate/tone
Pressured
Mumbled
Interventions Used This Session
CBT
DBT Skills
Motivational Interviewing
Psychoeducation
Safety Planning
Play Therapy
Family Therapy
Skill-Building (e.g., coping, social)
Other
Objective Observations
A:
Assessment
Risk Assessment
*
No SI/HI reported or observed
SI Assessed
HI Assessed
AVH Assessed
Safety Plan / Risk Mitigation
*
Progress on Treatment Plan Goals
Clinical Synthesis / Impression
P:
Plan
Plan for Next Session
Coordination of Care
Next Appointment
Clinician Name/Credentials
Clinician Signature
*
Clear
[Not Signed]
Date
*
Clear Form
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