SOAP Note Example for Anxiety Follow-Up Visit

What should you include in the subjective section?

In the subjective section, you'll want to capture the patient's own words about their anxiety symptoms since the last visit. Ask about any changes in their condition, new stressors, or how they feel overall. Here's an example:

• Chief Complaint: "I'm still feeling anxious, especially at work."
• History of Present Illness: The patient reports persistent anxiety over the past month, with increased episodes of restlessness and difficulty concentrating. They note that work stress has been a significant trigger.
• Current Medications: The patient is taking sertraline 50 mg daily and reports no side effects.
• Psychosocial: The patient mentions a recent increase in workload and limited time for relaxation.

What objective findings should you note?

The objective section should include measurable or observable data. This could be vital signs, mental status exams, or any other relevant observations. For an anxiety follow-up, you might include:

• Vitals: Blood pressure 120/80, heart rate 72 bpm.
• Appearance: The patient appears tense but is cooperative and engaged during the visit.
• Mental Status Exam: The patient is oriented to person, place, and time. Speech is normal, and thought process is logical.

How do you assess the patient's condition?

In the assessment section, summarize the patient's condition and progress. Consider any changes in symptoms or response to treatment:

• Diagnosis: Generalized Anxiety Disorder, stable.
• Progress: The patient shows some improvement with medication but continues to experience significant anxiety related to work stress.
• Risk Assessment: No suicidal ideation or self-harm behaviors reported.

What should your plan include?

The plan should outline the next steps in management. This could involve medication adjustments, therapy referrals, or lifestyle recommendations. For this example:

• Medication: Continue sertraline 50 mg daily. Consider increasing to 75 mg if symptoms persist at the next visit.
• Therapy: Recommend cognitive-behavioral therapy (CBT) sessions to help manage work-related stress.
• Follow-up: Schedule a follow-up visit in 4 weeks to reassess symptoms and treatment efficacy.
• Lifestyle: Encourage regular exercise and mindfulness practices to reduce stress levels.