SOAP Note Example for Anxiety Follow-Up Visit

What should you include in the Subjective section?

In the Subjective section, focus on the patient's own report of their symptoms and experiences since the last visit. Ask open-ended questions to get a full picture.

Example:

• Chief Complaint: "Feeling anxious most days."
• History of Present Illness: The patient reports increased anxiety over the past two weeks, especially in social settings. They mention difficulty sleeping and feeling on edge. They rate their anxiety as a 6/10, up from a 4/10 at the last visit.
• Current Medications: Sertraline 50 mg daily, taken consistently.
• Patient Concerns: Worried about upcoming work presentations and their impact on anxiety levels.

What details go into the Objective section?

The Objective section includes measurable data and observations. Note any changes since the last visit.

Example:

• Vital Signs: BP 120/80, HR 76 bpm, Temp 98.6°F
• Physical Exam: No significant findings. The patient appears well-groomed and makes eye contact.
• Mental Status Exam: Alert and oriented, mood appears anxious, speech is normal, thought process is logical.

How do you write the Assessment?

The Assessment summarizes your clinical judgment about the patient's condition based on the subjective and objective data.

Example:

• Diagnosis: Generalized Anxiety Disorder, stable but with recent increase in symptoms.
• Progress: Symptoms have worsened slightly since the last visit, possibly due to increased stressors.

What should you include in the Plan?

The Plan outlines your next steps for managing the patient's condition. This includes medication adjustments, therapy, follow-up appointments, and lifestyle recommendations.

Example:

• Medication: Increase Sertraline to 75 mg daily. Monitor for side effects.
• Therapy: Continue cognitive-behavioral therapy (CBT) sessions weekly.
• Follow-Up: Schedule a follow-up in four weeks to assess response to medication adjustment.
• Lifestyle: Encourage regular exercise and mindfulness practices to help manage anxiety.

Why is a SOAP note important for follow-up visits?

SOAP notes help you track a patient's progress over time. They provide a structured way to document changes and adjust treatment plans. This keeps you and your patient on the same page and ensures continuity of care.

By following this format, you can efficiently document an anxiety follow-up visit, ensuring you capture all necessary information while providing clear guidance for ongoing treatment.