Psychiatric SOAP note example: a complete annotated ADHD follow-up note
SOAP is the format most of us trained on, and it works fine for psychiatry if each letter carries the right content. The most common failure I see when I read mental health SOAP notes is not missing content. It is content in the wrong section: a mental status exam pasted into Subjective, a patient's self-report restated in Objective as if it were observed, an Assessment that retells the story instead of reasoning about it. Sort every sentence into the right bucket and the same note suddenly reads as defensible.
This guide covers what each SOAP section should carry in a psychiatric note, then walks through a complete annotated example: a stable adult ADHD stimulant follow-up, one of the highest-volume and most closely reviewed visit types in outpatient psychiatry.
What each letter carries in a psychiatric note
Use the four rows below as your psychiatry SOAP note template. Everything in the example that follows sorts into one of them.
| Section | What it holds |
|---|---|
| S (Subjective) | The patient's report: interval history since the last visit, symptoms in the patient's own words with direct quotes, medication adherence as they describe it, side effects, stressors, and functioning. |
| O (Objective) | What you observed and measured. The mental status exam is the psychiatric physical exam and it anchors this section, alongside vitals when the regimen makes them relevant and any scale scores administered today. If the patient told you, it is not Objective, with one conventional exception: elicited MSE findings such as stated mood and reported suicidal or homicidal ideation belong in O, because they are findings of the exam you performed. |
| A (Assessment) | The DSM-5-TR diagnosis with its ICD-10 code and status (stable, partial response, worsening), plus one or two sentences of clinical reasoning that connect S and O to that conclusion. |
| P (Plan) | The decisions: medication continued or changed with a rationale, therapy, labs or monitoring, safety planning when indicated, and the follow-up interval. |
The example note
The patient below is fictional. This is a maintenance visit: a 29-year-old doing well on a stimulant at month four. Stable visits are exactly where SOAP discipline earns its keep, because the temptation to write three thin lines is strongest at the moment a controlled substance is being continued.
Psychiatric SOAP note: adult ADHD stimulant follow-up (established patient)
Chief complaint: "This is the first quarter I've actually finished my reports on time."
S - Subjective: D.K. is a 29-year-old returning for follow-up of ADHD, combined presentation, at month 4 on lisdexamfetamine 50 mg each morning. Reports taking it daily as prescribed with no missed doses; the last fill lasted the full 30 days. Benefit is consistent through the workday and "wears off around six, which honestly is fine, I want my evenings back." Appetite remains reduced through midday; he eats a normal dinner and feels his weight has been steady. Sleep onset by 11 pm with the dose taken before 8 am; no initial insomnia since moving the dose earlier at the last visit. No anxiety, irritability, or jitteriness. Denies taking extra doses, running out early, or sharing medication. Alcohol one to two drinks on weekends; no cannabis, no nicotine, no other stimulant use.
O - Objective: BP 122/78, HR 76. Weight 172 lb, stable from 173 lb at last visit. Mental status: on time, casually dressed, well groomed. Calm and cooperative with good eye contact. Speech normal rate and rhythm. Mood "pretty good," affect euthymic with full range. Thought process linear and goal directed. No psychomotor agitation, no tics. Denies suicidal or homicidal ideation; no evidence of psychosis. Insight and judgment good.
A - Assessment: F90.2 attention-deficit/hyperactivity disorder, combined presentation. Stable on current regimen. At month 4 on lisdexamfetamine 50 mg, target symptoms (sustained attention, task initiation, follow-through at work) remain well controlled; side effects are limited to tolerable midday appetite suppression with stable weight, and there is no cardiovascular signal and no indicator of misuse, so the risk-benefit balance favors continuing the current dose unchanged.
P - Plan:
1. Continue lisdexamfetamine 50 mg every morning. Symptoms well controlled and side effects tolerable at this dose; no indication to titrate.
2. Monitoring: BP, HR, and weight at each visit while on stimulant therapy. Today's values reviewed and within normal limits.
3. State prescription monitoring program reviewed; findings consistent with prescribed therapy.
4. Refill: lisdexamfetamine 50 mg, quantity 30, no refills.
5. Follow-up in 4 weeks. Will consider spacing visits once stability is sustained, where state rules and clinic policy allow; return sooner for recurrence of symptoms, appetite or sleep change, or any cardiovascular symptoms.
SOAP is a lens, not a different standard
Format changes where content sits, not what content is required. The same four proofs described in the psychiatric progress note example apply here: interval change, current status, risk, and a decision with a rationale. In SOAP, interval change lives in S, current status and a brief risk statement live in O, the decision lives in P, and A holds the reasoning that ties them together. Rating scales follow the same logic: the score you administered today belongs in O, with the interpretation and response in A or P, as covered in the PHQ-9 and GAD-7 documentation guide. And none of this changes how the visit is billed. The E/M level still rests on medical decision making, as laid out in the 99214 with 90833 billing guide.
Common SOAP failures in psychiatry
- No mental status exam. An O section holding nothing but vitals is the psychiatric equivalent of an internist documenting no physical exam. The MSE is the exam; it belongs in every visit note.
- Subjective symptoms restated in O as if observed. "Patient is sleeping poorly" is a report, not an observation. In O it reads as an exam finding you never made.
- An A that repeats S. If your Assessment restates what the patient said, it is a second Subjective. A carries the diagnosis, its status, and your reasoning, nothing else.
- A P with no rationale. "Continue lisdexamfetamine 50 mg" says what you did. Adding why (controlled symptoms, tolerable side effects, no misuse indicators) is what makes the decision defensible.
- Risk assessment missing because no letter obviously owns it. It has a home: a brief risk statement sits in O as part of the MSE, and any risk decision (safety planning, means restriction, escalated follow-up) sits in P.
Frequently asked questions
Should therapists use SOAP or DAP?
DAP (Data, Assessment, Plan) is common in therapy settings and essentially merges S and O into one Data section. Either format works if the note is session-specific and linked to treatment goals. Reviewers care about the content, not the acronym.
Are vitals required in a psychiatric SOAP note?
It depends on the setting and the regimen. For patients on stimulants, and on certain other agents with cardiovascular or metabolic effects, documenting BP, HR, and weight at each visit is widely expected good practice. For a therapy-only visit, vitals are usually unnecessary.
How long should a psychiatric SOAP note be?
Long enough to carry the four proofs: interval change, current status, risk, and a reasoned decision. For most follow-ups that is well under a page. Length past that point adds liability surface, not credibility.
Where does the psychotherapy add-on go?
In a separately documented section after the SOAP body, and it belongs there when, under CPT time rules, 16 or more minutes of psychotherapy actually happened during the visit. See the annotated 90833 note example for exactly what that section needs to contain.
Can an AI scribe draft SOAP notes?
Yes. SOAP is one of the three note formats OneStep Scribe drafts from the visit audio, alongside progress and evaluation notes. Judge any vendor the same way: run a trial and look at the note you would actually sign, section by section, against the standards above.
OneStep Scribe listens to the visit and drafts SOAP, progress, and evaluation notes with the patient's own words, built for psychiatrists, PMHNPs, therapists, psychologists, and other mental health providers. Every account is NPI-verified, and every note is yours to review and sign.
Start a 14-day free trialThis article is educational and reflects one clinician's documentation approach. It is not legal, billing, or clinical advice, and it does not guarantee reimbursement. CPT is a registered trademark of the American Medical Association. The patient described is fictional. Controlled-substance monitoring requirements vary by state. Always verify requirements with your payers, your state board, and your compliance advisors.