SOAP Notes For Psychiatry Template
A simple-to-use psychiatry SOAP notes template in an editable PDF format to help you improve communication, productivity, and clinical outcomes.
Fact Checked by Ericka Pingol.
What is a Psychiatry SOAP Notes Template?
Our template is specially designed for psychiatrists to document their clinical notes in an efficient and structured way. Psychiatrists can use Carepatron’s simple-to-use psychiatry SOAP Notes template to ensure their notes meet the internationally recognized SOAP format. SOAP notes are one of the most widespread medical note-taking formats across the world due to their simplicity, reproducibility, and ease of being shared across different providers.
The SOAP format stands for the four key sections of the SOAP note; Subjective, relating to the recent, subjective experiences of the patient; Objective, which refers to any quantitative clinical data such as medication dosage, height, or weight; Assessment, relating to the clinician’s impression of the patient from this encounter; and Plan, a summary of the next steps in the patient’s treatment plan. For more on SOAP notes in general, check out Carepatron’s introduction to SOAP notes.
In psychiatry in particular, where a range of complex qualitative and quantitative data must be accurately recorded, SOAP notes provide a great way to clearly and concisely document key findings from a patient encounter. Using the Carepatron SOAP Note template for psychiatry couldn’t be simpler, just follow the four easy steps or check out the explainer video.
Free SOAP Notes For Psychiatry Template
Check out these SOAP notes for psychiatry templates to improve your clinical notes, productivity, and mental health outcomes.
How To Use This SOAP Note Template for Psychiatry
This SOAP Note template is great as it serves as a standardized format for note-taking, but also as a guide to the clinical encounter itself. Follow these steps to use our psychiatric SOAP note template.
Download Carepatron’s Psychiatry SOAP Notes Template
Our template has the key sections already set out and ready for you to fill in! Just hit download and you will have your own copy of the PDF psychiatry SOAP Notes template.
Fill in patient and encounter information
At the top of the template, there is space for key information that must be filled in every time the template is used. This includes the patient’s name, date of birth, and optional extra identifier (e.g. MRN, NHS number of NHI). Additionally, the date and time of the patient encounter should be noted here for record-keeping purposes.
Fill in the SOAP sections of the template
Starting with the patient’s subjective experience in the ‘Subjective’ section, continue filling out the four main body sections of the template. The amount of time you spend on each of the SOAP sections depends on your psychiatry practice, and the finished template will naturally be a bit different between practitioners.
Safely store the record
Once the template is completed and all the information you want to note down from this encounter is recorded, it’s time to make sure your SOAP note is safely stored for future use. Psychiatric notes contain sensitive patient information and therefore they must be stored securely and safely. Carepatron provides a HIPAA-compliant way to electronically store your patient notes, ensuring the information is both secure and on hand whenever and wherever you need to access them.
Psychiatry SOAP Note Example (Sample)
Sometimes the best way to understand how to do something yourself is to see what the finished product looks like!
While different psychiatric practitioners will each fill out our template a little differently, an example of a completed psychiatric SOAP Note using our template.
Download this Psychiatry SOAP Note example here:
Who Can Use This Psychiatry Template?
This template is designed for anyone who routinely assesses and treats psychiatric patients. While this would typically be a psychiatrist, this template could also be used by healthcare workers, support staff, or allied health professionals who contribute to the patient’s care. They might be:
- Psychiatrists or psychiatric residents,
- Nurses or nurse practitioners specializing in psychiatric nursing,
- Health workers in prison, community or hospital psychiatric departments,
- Any other healthcare workers in psychiatric settings who routinely assess patients.
This psychiatric SOAP notes template can be used across the many specialties within psychiatry, such as geriatric, pediatric, forensic, general, or addiction psychiatry. Depending on the specialty of the practitioner, sections of the SOAP notes may be given different priorities, but our psychiatric SOAP Notes template itself is general enough for use across all psychiatric specialties.
Why is This Template Useful For Psychiatrists?
Don’t leave anything out
There’s nothing worse than leaving a patient encounter and realizing you’ve forgotten to ask a crucial question! If you use our psychiatric SOAP notes template, you can be sure you’ve got the key qualitative and quantitative information recorded, as well as your assessment and next steps for the patient, every time.
Spend less time formatting
Using this pre-made template for psychiatric SOAP notes means more time for the important questions you have for your patient, and less time spent formatting notes.
Make sure others can pick up where you left off
Patients are not always seen by the same psychiatrist, and may even transfer between departments throughout their care journey. Starting with a widely used and recognized clinical format, like our psychiatric SOAP Notes template, is a great way to make sure another practitioner can quickly pick up where you have left off if needed.
Why Use Carepatron for Psychiatry SOAP note?
Carepatron provides a fantastically integrated solution to psychiatry SOAP note creation, storage, and access. Follow-up appointment scheduling, further communication with your patient, and other actionable tasks created from a patient’s psychiatric SOAP Notes can all be completed from within Carepatron’s unified practice management software.
Using Carepatron for psychiatric SOAP Notes also minimizes the time spent copying information between different systems, as everything you need is securely stored in one place. You can access patient data, complete your clinical documentation and store your progress notes on a single platform. This type of integration greatly benefits productivity and workflow, as you don’t have to spend time navigating multiple systems and accessing the information on different platforms.
Finally, Carepatron provides a wide range of clinical templates, completed example templates, and resources to ensure you’re providing the best care for your patients.
Commonly asked questions
This is a tough question as every psychiatrist will have different preferences for how they fill in their SOAP Notes template. It can be easier to agree on what does not make for good psychiatric SOAP notes:
- Notes that use large amounts of technical jargon or infrequently used acronyms can be hard for others to understand.
- Making notes too long or including irrelevant information can make it hard to find the important points when referring back to the notes.
- And finally, keep it accurate but avoid adding overly judgmental comments.
This depends on what kind of information you are needing to record. Our psychiatry SOAP note template has four key sections already laid out which separate out information based on the internationally recognized SOAP note-taking format.
For example, planned changes to a psychiatric patient’s medication following an encounter with their psychiatrist would get put under the Plan heading, however, the patient’s feelings in response to a new medication would belong under the Subjective heading.
Psychiatrists have the legal responsibility to securely store their patient records, including clinical notes such as psychiatric SOAP Notes. Electronic health records (EHR) are the best way to ensure your notes are accessible, safe, and secure. Storing this template within Carepatron ensures your patient’s psychiatric SOAP Notes can be shared, updated, and accessed in a timely manner.
