Write an Example SOAP Note

Question

Examlex · Accepted Answer

The Answer is -S Met with student for 30 minutes.Student indicated that he is feeling a lot of pressure around school work (e.g., not sleeping at night, unable to relax, wanting to give up).He also noted worries about which colleges to attend and how to afford his education.Student would like to bring his grades up and begin to feel more at ease.Right now he describes his situation as "impossible."
-O Student appeared quite anxious and perhaps depressed.He rubbed his hands on the tops of his legs throughout our conversation.He also did not make eye contact and did not appear to be as well groomed as usual (e.g., shirt untucked, hair not combed).At the end of the session, he appeared a bit more relaxed.
-A Student appears to be experiencing a great deal of stress related to school work and future educational plans.This anxiety may be interfering with his sleep and result in his feeling tired and down.As an initial baseline, I asked the student to rate the level of anxiety he is experiencing (1 = relaxed, 10 = overwhelmed).He provided a rating of "7."
-P Next week, I plan to explore current stressors with the student.He also expressed interest in learning relaxation exercises that he can practice at home and in class.During the week, he will note those times when he feels most and least stressed.

Write an Example SOAP Note

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