SOAP Note Example for a Depression Follow-Up Visit

What should the Subjective capture at a depression follow-up?

The Subjective is the patient's story in their own words, plus interval history since the last visit. For a depression follow-up, anchor it to change over time and treatment response rather than re-listing the original diagnosis.

• Interval mood and symptoms — sleep, appetite, energy, concentration, anhedonia, and any new stressors.
• Medication adherence and side effects — what they're taking, how consistently, and how they feel on it.
• Function — work, relationships, and daily activities, which often track recovery better than mood alone.
• Patient goals and concerns — what they want from treatment and any reservations.

How do you document a PHQ-9 in the note?

Record the total score, the date, and how it compares to the prior visit so the trend is visible at a glance. Treat the score as one data point that supports—never replaces—your clinical judgment.

• Score and severity band — e.g., "PHQ-9 = 11 (moderate), down from 17 (moderately severe) four weeks ago."
• Item 9 — always note the response to the self-harm/passive ideation item and any follow-up you did.
• Context — note partial response, response, or remission to justify your plan.

What goes in the Objective and Assessment?

The Objective holds observable, measurable findings: vital signs if taken, relevant labs, and a focused mental status exam (appearance, behavior, speech, mood/affect, thought process, cognition, insight). The PHQ-9 score lives here too as a structured measure. The Assessment then synthesizes everything into a concise clinical impression.

• Diagnosis and status — e.g., "Major depressive disorder, recurrent, moderate — improving, partial response."
• Treatment response — link symptom change to the current intervention.
• Risk statement — an explicit, dated assessment of suicide and safety risk.

What does a complete sample note look like?

Here is one concrete, original example for a 34-year-old patient returning four weeks after a dose adjustment. Adapt wording to your own clinical voice and setting.

SUBJECTIVE:
34 y/o returns for depression follow-up, 4 weeks after sertraline increase to 100 mg daily. Reports mood is "a bit lighter" and she is sleeping more regularly (6-7 hrs vs. 4 prior). Energy still low some mornings but improving. Resumed walking with a friend twice this week. Appetite normal. Denies new stressors; work feels "manageable again." Taking sertraline daily with good adherence; no significant side effects, mild early nausea resolved. Denies current thoughts of self-harm or suicide.

OBJECTIVE:
Vitals stable, BP 118/74, HR 72. Alert, well-groomed, cooperative. Speech normal rate/tone. Mood "okay," affect mildly constricted but reactive and brighter than last visit. Thought process linear, goal-directed. No psychosis. Insight and judgment good. Cognition grossly intact.
PHQ-9 = 11 (moderate), down from 17 (moderately severe) at last visit. Item 9 = 0 (no thoughts of self-harm).

ASSESSMENT:
Major depressive disorder, recurrent, moderate - partial response to sertraline 100 mg with improving sleep, energy, and function. PHQ-9 trending down (17 to 11). Safety/risk: low acute risk today - denies ideation, intent, or plan; item 9 = 0; future-oriented with active supports and no access concerns identified. No indication for higher level of care.

PLAN:
1. Continue sertraline 100 mg daily; allow full 4-6 weeks at current dose before reassessing for further titration.
2. Reinforce behavioral activation (walks, social contact, sleep routine).
3. Referral to outpatient psychotherapy (CBT) provided; patient agreeable.
4. Reviewed safety plan; patient knows to call clinic or crisis line and to seek emergency care if thoughts of self-harm emerge.
5. Repeat PHQ-9 and follow up in 4 weeks; sooner if symptoms worsen.
6. Discussed expected timeline and that ongoing improvement is the goal. Patient verbalized understanding.

How do you write the Plan so it's actionable?

A good Plan is specific and numbered so the next clinician (or the patient) knows exactly what happens next. Tie each item to the Assessment.

• Medication decision — continue, titrate, switch, or augment, with rationale and timeframe.
• Psychotherapy and behavioral steps — referrals, behavioral activation, sleep hygiene.
• Safety planning — what was reviewed and the return precautions you gave.
• Follow-up — interval, what you'll re-measure, and red flags that warrant sooner contact.

How can you make notes faster without losing quality?

Documentation eats clinical time, and depression follow-ups are high-volume. An AI medical scribe like Doctor Notes can draft the SOAP structure from your visit conversation—pulling the PHQ-9, med response, and plan into place—so you edit instead of typing from scratch. You stay the author and clinical decision-maker; the tool just removes the blank page.

Where should the PHQ-9 score go in a SOAP note?

Put the numeric PHQ-9 score in the Objective section as a structured measure, then interpret its meaning (severity and trend) in the Assessment. This keeps raw data separate from your clinical reasoning, which makes the note easier to audit and easier for the next clinician to follow.

How do you document a suicide-risk assessment safely?

Document what you actually asked and what the patient reported—ideation, intent, plan, access to means, and protective factors—then state your risk level and the actions you took. Be specific and non-judgmental, note any safety planning and return precautions, and avoid vague phrases like "no SI" in isolation; a brief, concrete rationale protects both the patient and you.

Does a follow-up note need to repeat the full history?

No. A follow-up should focus on the interval since the last visit—what changed, how the patient responded to treatment, and the updated plan. Reference the established diagnosis and prior workup briefly rather than re-documenting the entire initial evaluation, which keeps the note concise and clinically useful.