Psychiatry Follow-up SOAP Note     ( Four different samples) 1 Week from Inpatient Care  Age: 41 Years Gender: F Chief Complaint: ”Follow-up after hospitalized”  S- Patient states that she generally has been doing well.

Psychiatry Follow-up SOAP Note     ( Four different samples)

1 Week from Inpatient Care

 Age: 41 Years

Gender: F

Chief Complaint: ”Follow-up after hospitalized” 

S- Patient states that she generally has been doing well. Depressive symptoms have improved but she still feels down at times. Sleeping better, reports 7-8 hours of restful sleep each night. She feels the fluoxetine is helping somewhat and without any noticeable side effects. Hydroxyzine has been helpful for anxiety symptoms; she reports using this as a PRN 3-4 times over the past week. She has no suicide plan and has not thought about suicide since her attempt prior to recent hospitalization. She has no access to prescription medications, other than the fluoxetine and hydroxyzine, or other lethal means. She continues to practice coping skills she learned while inpatient, and has also coordinated individual therapy which she starts next week.

O- Vitals: T 98.4, P 82, R 16, BP 122/78 General: alert and oriented to person, place, time, and situation. Affect is congruent with mood; brightens with interaction. She does not appear to be in physical distress. Speech: regular rate, pitch, volume, articulation, coherence, production, vocabulary and spontaneity. Thought Process: no circumstantiality, tangentiality, loosening of associations, flight of ideas, derealization, depersonalization, grandiosity, dissociative events or concreteness. Associations: Intact. Abnormal thoughts: None reported. Judgement & Insight: recognizes emotional problems and is motivated for treatment. Memory: able to repeat 3 out of 3 words immediately, able to recall 3 out of 3 words after a few minutes. Attention: attends to tasks normally. Language: able to name common objects, speech with normal flow and content. Fund of knowledge: average, aware of current events. Labs: reviewed from hospital records. CBC, CMP, Vitamin D, and TSH all within normal limits.

A- Major Depressive Disorder, recurrent, severe without psychotic features (F33.2); Generalized Anxiety Disorder (F41.1)

P- Increase fluoxetine to 20mg daily since this has been well-tolerated but moderately effective for symptoms of depression and anxiety. Continue hydroxyzine 25mg TID PRN for anxiety. Continue outpatient therapy as scheduled. Follow-up in two weeks or earlier if any depressive symptoms worsen.  CPT: 99205; ICD-10: Major Depressive Disorder, recurrent, severe without psychotic features (F33.2); Generalized Anxiety Disorder (F41.1)

Psychiatry follow-up SOAP note

Outpatient medication management

 Age: 63 Years

Gender: M

Chief Complaint: ”Follow-up after change in medications”

S- Presents for 4-week medication management follow up. Last seen 7/31, at which time we increased sertraline to 150 mg and continued quetiapine 50 mg HS PRN and propranolol 20 mg BID PRN. Reviewed interim history. He has been taking his medication on a regular basis and denies side effects. Anxiety and depression have improved with the increase of sertraline. PHQ-9 is 5, GAD-7 is 7 today. Also indicates improved energy and decreased anhedonia. Reports average of 8 hours of restful, restorative sleep each night with quetiapine. Propranolol remains effective for social anxiety, which he takes prior to hosting Zoom presentations at work. He is somewhat anxious about returning to work in-person, as he has been working remotely from home since the pandemic began. Endorses suicidal ideation that is fleeting and passive with no plan, drive, or intent. He has no history of self-harm and this appears to be at baseline for him. He describes having adequate support, and continues to see his long-term therapist bi-weekly. Reviewed crisis plan. Appetite is stable. No new medical concerns.

O- Vitals: T 98.6, P 78, R 18, BP 118/80 General: alert and oriented to person, place, time, and situation.. Euthymic, appropriate affect, good eye contact, smiles easily.  Appears stated age, well nourished, appropriately groomed and dressed for weather. Normal gait and posture, no abnormal or involuntary movements. Speech: normal rate, rhythm, tone and volume.  Thought Process: Linear, goal oriented. Appropriate for circumstance, setting, and situation. Abnormal thoughts: preoccupations. Judgement & Insight: recognizes emotional problems and is motivated for treatment. Memory: intact for recent and remote events. Attention: attends to tasks normally. Language: expressive and receptive communications skills are normal. Fund of knowledge: demonstrates a good fund of knowledge. Labs: reviewed CBC, CMP, Vitamin D ordered last visit; unremarkable except Vitamin D is low at 10 ng/mL.

A- Major Depressive Disorder, recurrent, moderate (F33.1); Social Phobia, generalized (F40.11); Insomnia due to other mental disorder (F51.05)

P- Start Vitamin D3 50,000 IU weekly for Vitamin D deficiency. Continue sertraline 150mg daily for mood and anxiety, quetiapine 50mg HS PRN for insomnia, and propranolol 20mg BID PRN for social anxiety.  Continue outpatient therapy as scheduled. Return to care in 8-12 weeks or sooner as needed. 

CPT 99214; ICD-10: Major Depressive Disorder, recurrent, moderate (F33.1); Social Phobia, generalized (F40.11); Insomnia due to other mental disorder (F51.05)

Psychiatry Group Therapy SOAP Note

Group Type: (e.g., Process group, CBT skills group, psychoeducation group, trauma-informed group)
Session Focus/Theme: (e.g., coping skills, emotional regulation, anxiety management, interpersonal boundaries)
Student Role: (e.g., co-facilitator, active observer, lead facilitator)

Number of Participants: ___
Duration of Group: ___ minutes

S – Subjective

Group members reported experiences and reflections related to the session theme. Commonly expressed concerns included:

• (e.g., increased anxiety related to interpersonal stressors, difficulty managing emotions, challenges with boundaries, mood instability)

Selected patient statements (paraphrased, de-identified):

• “I hate when my family puts me down in front of my friends.”
• “Drugs always alleviated my stress”

Several members described utilizing coping strategies outside of the group, with varying levels of effectiveness. No group member expressed active suicidal or homicidal intent during the session. Safety was verbally assessed at the group level, and members were reminded of crisis resources as appropriate.

O – Objective

Group Observation:

• Members were alert and oriented to person, place, time, and situation.
• Participation ranged from passive listening to active verbal engagement.
• Affect across the group was (e.g., congruent, anxious, constricted, euthymic).
• Speech was generally normal in rate, tone, and volume.
• Thought processes appeared linear and goal-directed overall, with no overt psychotic symptoms observed.

Behavioral Observations:

• Eye contact: (appropriate / intermittent / limited)
• Engagement: (consistent / variable)
• Psychomotor activity: no agitation or abnormal movements noted

No acute safety concerns observed during group.

A – Assessment

Group members presented with symptoms consistent with their established psychiatric diagnoses. Overall clinical presentation suggests:

• Continued benefit from group psychotherapy interventions
• Progress toward treatment goals related to (e.g., insight development, coping skill acquisition, emotional regulation)

Primary Psychiatric Diagnoses Addressed in Group:

• (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, PTSD, Adjustment Disorder)

P – Plan

• Continue participation in scheduled group psychotherapy sessions.
• Reinforce use of coping strategies discussed during group (e.g., grounding techniques, cognitive reframing, behavioral activation).
• Encourage members to continue individual therapy and medication management as prescribed.
• Crisis resources reviewed and reinforced.
• Follow up at next scheduled group session.

CPT Code: 90853 – Group Psychotherapy

ICD-10 Codes:

• (List primary diagnoses addressed during group)

Age: 63 Years
Gender: M

Chief Complaint: “Weekly Psychotherapy Visit”

S (Subjective):
Presents for ongoing psychotherapy session. Reviewed interval history since last visit. Patient reports continued improvement in anxiety and depressive symptoms, noting better energy, decreased anhedonia, and improved overall functioning. He continues to experience mild anxiety related to returning to in-person work after prolonged remote work during the pandemic.

He describes utilizing coping strategies discussed in prior sessions, including preparation for presentations and cognitive reframing, which he finds helpful. He continues to attend work-related Zoom presentations and reports manageable anxiety in these settings.

Sleep is reported as restorative, averaging approximately 8 hours per night. Appetite remains stable.

Endorses intermittent, fleeting passive suicidal ideation without plan, intent, or desire to act. Denies history of self-harm. Reports strong support system and ongoing engagement with long-term therapist bi-weekly. Crisis plan reviewed and patient verbalizes understanding.

No new medical concerns reported.

O (Objective / Mental Status Exam):
Alert and oriented to person, place, time, and situation.
Appearance: well-groomed, appropriately dressed, appears stated age.
Behavior: cooperative, good eye contact.
Mood: euthymic.
Affect: appropriate, congruent, full range.
Speech: normal rate, rhythm, tone, and volume.
Thought Process: linear, logical, goal-directed.
Thought Content: mild preoccupations; no delusions or active SI/HI.
Cognition: intact (memory, attention, concentration).
Insight/Judgment: good; recognizes symptoms and engaged in treatment.

A (Assessment):

• Major Depressive Disorder, recurrent, moderate (F33.1)
• Social Anxiety Disorder (F40.11)
• Insomnia related to mental disorder (F51.05)

Patient demonstrates continued improvement in mood and anxiety symptoms with ongoing psychotherapy. Residual anxiety persists in the context of the anticipated return to in-person work. Passive SI remains at baseline without escalation. Risk assessed as low at this time.

P (Plan):

• Continue individual psychotherapy focusing on:
  • Cognitive behavioral strategies for anxiety
  • Exposure-based techniques for social anxiety
  • Coping skills for transition back to in-person work
• Reinforced use of coping strategies and behavioral activation
• Reviewed and reinforced safety/crisis plan
• Encourage continued engagement with support systems
• Follow up for psychotherapy in 1–2 weeks or as clinically indicated

CPT Code: 90834 (Psychotherapy, 45 minutes) (or adjust to 90837 if 60 minutes)

ICD-10 Codes:

• F33.1 Major Depressive Disorder, recurrent, moderate
• F40.11 Social Anxiety Disorder
• F51.05 Insomnia due to other mental disorder