Last Updated on May 4, 2023 by Ossian Muscad
Mental health is an important factor in overall well-being, and healthcare professionals must have access to the best resources when providing care. One such resource is a mental health SOAP note template—a comprehensive guide that helps providers create thorough, accurate notes about their patient’s mental health status.
In this article, we’ll explain what a mental health SOAP note template is, how to use it effectively, and why it’s so beneficial for patients and providers. We’ll also provide some tips on creating a customized template that meets your specific needs. By the end of this article, you’ll be ready to start using these templates in your practice right away!
What is a Mental Health SOAP Note Template?
A Mental Health SOAP Note Template is a standardized document used in mental health care to record information about a patient. “SOAP,” or Subjective, Objective, Assessment, and Plan, is divided into four sections, each containing specific information related to the patient’s mental health.
The Subjective section captures the patient’s experiences and feelings, while the Objective section covers observable data like vital signs and physical exams. The Assessment section evaluates the patient’s mental health status based on subjective and objective data, and the Plan section outlines the course of action for the patient’s care. Mental Health SOAP notes are critical to ensure continuity of care and effective communication between mental health professionals.
Benefits of Using a Mental Health SOAP Note
When used correctly, a mental health SOAP note template can benefit both patient and provider. With that said, here are some of the notable benefits that a mental health SOAP note can bring to the table:
Comprehensive Documentation
A Mental Health SOAP Note comprehensively records the patient’s mental health information. This helps to ensure that all aspects of the patient’s care are considered and documented, enabling mental health professionals to make informed decisions.
Improved Communication
Because Mental Health SOAP Notes are standardized, mental health professionals can easily share information with colleagues, ensuring that everyone involved in the patient’s care is up to date on their mental health status. This improves team members’ communication and helps ensure that patients receive the best possible care.
Better Decision-making
A Mental Health SOAP Note captures subjective and objective data relevant to the patient’s care. This means mental health professionals can make informed decisions based on the available data, leading to better care outcomes and improved patient outcomes.
Improved Patient Care
Using a Mental Health SOAP Note enables mental health professionals to clearly understand the patient’s mental health status. This helps them provide targeted care interventions tailored to the patient’s needs, resulting in improved patient outcomes.
Legal Protection
A Mental Health SOAP Note provides a record of the care provided to the patient. This can be used as legal protection for the mental health professional and the healthcare facility in the event of a malpractice claim or other legal dispute. By using a standardized documentation system, mental health professionals can feel confident that they are providing high-quality care that is well-documented and defensible.
What Items to Include in a Mental Health SOAP Note?
As mentioned earlier, a mental health SOAP note has four main sections: subjective, objective, assessment, and plan. Here is a breakdown of what needs to include in each section:
Subjective
The Subjective section includes information about the patient’s thoughts, feelings, and subjective experiences. This section might include details about the patient’s current emotional state, any symptoms they are experiencing, and any stressors they face.
Objective
The Objective section includes objective data about the patient, such as vital signs, physical exam findings, and laboratory results. This section might include information about the patient’s body mass index, blood pressure, respiratory rate, and other physical measures relevant to the patient’s mental health care.
Assessment
The Assessment section includes evaluating the patient’s mental health status based on the subjective and objective data presented in the previous sections. This section might include information about the patient’s diagnosis, any relevant risk factors, and the overall prognosis for the patient.
Plan
The Plan section outlines the course of action that will be taken to address the patient’s mental health needs. This section might include information about the medications that will be prescribed, any therapies or interventions that will be recommended, and any referrals that will be made. This section should also include a timeline for follow-up care and any recommendations for ongoing management of the patient’s mental health.
Other information
In addition to the key sections above, Mental Health SOAP Note Templates might include other areas for recording important information. For example, the template might consist of areas for documenting information about the patient’s social and family history, relevant cultural considerations, or details about the patient’s insurance coverage or financial situation.
A Mental Health SOAP Note template aims to provide a thorough and standardized way to record key information about the patient’s mental health status and facilitate effective communication and decision-making among mental health professionals.
Example Mental Health SOAP Note
To give you a better understanding of what a Mental Health SOAP Note might look like, here is an example template:
Mental Health SOAP Note
Patient Information
- Name: John Doe
- Age: 32
- Gender: Male
- Date of Assessment: 04/01/2023
Subjective
The patient reports feeling overwhelmed and stressed due to his recent divorce and job loss. He reports feeling anxious most of the time and having difficulty sleeping. He reports his appetite has decreased, and he has lost weight.
Objective
Vital signs:
- Blood pressure: 118/78 mmHg
- Respiratory rate: 16 breaths per minute
- Heart rate: 78 beats per minute
- Height: 5 feet 10 inches
- Weight: 160 pounds
Physical exam findings:
- The patient appears anxious and fidgety
- No observable physical abnormalities
Assessment
Based on John’s subjective and objective information, he meets the criteria for Generalized Anxiety Disorder. He is also at risk for depression due to his recent life stressors.
Plan
- The patient will be referred to a therapist to learn coping skills for managing anxiety and stress.
- The patient will be prescribed an SSRI, starting at a low dose and increasing as needed and as tolerated, to manage his anxiety and prevent depression.
- Follow-up appointments will be scheduled in 2 weeks to assess medication efficacy and side effects.
Additional Information
- Social/family history: The patient is divorced and currently living alone. He has no children. He has a history of alcohol use disorder, which he reports having quit 2 years ago.
- Insurance coverage: The patient reports having insurance through his previous employer, which will end at the end of the month. He is in the process of finding new insurance coverage.
This SOAP note provides a clear, concise record of the patient’s mental health status, including subjective and objective information, assessment, and plan for care. Shared it with other healthcare professionals to ensure continuity of care.
Create Mental Health SOAP Note Templates Using a Low-code Platform
Now that you know the basics of a Mental Health SOAP Note template, you may be wondering how to create one for your practice. A great way to do this is with a low-code platform like DATAMYTE. Low-code platforms allow users to build and deploy applications quickly and easily without writing code from scratch.
With DATAMYTE, you can create custom Mental Health SOAP Note Templates tailored to your practice’s needs. DATAMYTE’s platform automates data collection and makes sharing information with other healthcare professionals easy and secure.
DATAMYTE is a quality management platform with low-code capabilities. The DataMyte Digital Clipboard is a low-code workflow automation software with a built-in checklist and smart form builder. This feature, along with its drag-and-drop interface, allows you to create any checklist and form template you need—including mental health SOAP note templates.
To create a checklist or form template using DATAMYTE, follow these steps:
- Log in to DATAMYTE and navigate to the ‘Checklist’ module.
- Click “Create Checklist” to create a new checklist or form template.
- Add a Title to the checklist or form template; select the category it belongs to.
- Click “Add Item” to add items to the checklist or form template.
- Add appropriate descriptions to each item, the type of answer required, and other relevant specifications, such as reference documents, acceptance criteria, or potential limits.
- Assign the personnel responsible for completing the checklist.
- Indicate any required approvals from other relevant personnel, such as supervisors or quality assurance managers.
- Save your checklist; it will now be available on any device. You can also print a physical copy of your checklist.
DATAMYTE also lets you conduct layered process audits, a systematic review of critical process steps. This auditing method focuses on the areas with the highest risk of failure or non-compliance. By conducting LPA using DATAMYTE, you can effectively identify and correct defects before they escalate.
With DATAMYTE, you have the perfect solution for creating and implementing mental health SOAP note templates. Book a demo with us today to learn how DATAMYTE can help you provide your patients with the best mental health care.
Conclusion
This article covered important information on creating a mental health SOAP note template. With this knowledge, you can now create and use custom templates tailored to your practice’s needs and ensure continuity of care for your patients. DATAMYTE is a great low-code platform with the tools to make creating and implementing mental health SOAP note templates easy.
