SOAP Notes for Psychiatric Nursing

In psychiatric nursing, documenting observations, assessments, and care plans using the SOAP (Subjective, Objective, Assessment, Plan) format is essential for accurate, consistent mental health care. SOAP notes for psychiatric nursing provide a structured framework to capture subtle changes in mood, behavior, and thought patterns, supporting effective care planning and communication among mental health providers. This article explores how psychiatric nurses can use SOAP notes to document mental health observations and create patient-centered care plans.

Key Considerations for Psychiatric SOAP Notes

Patients in psychiatric care may experience various mental health challenges, from mood disorders to behavioral issues. Effective SOAP notes help psychiatric nurses capture a comprehensive picture of the patient’s mental state, progress, and treatment needs. SOAP notes for psychiatric nursing require precision, empathy, and careful observation to accurately document and address patients’ mental health concerns.

1. Subjective (S): Capturing Patient-Reported Thoughts and Feelings

The Subjective section of psychiatric SOAP notes should include the patient’s own words and descriptions of their mental state. This section is crucial for understanding the patient’s perspective on their symptoms, emotional challenges, and overall well-being.

Consideration: Many psychiatric patients struggle with expressing their emotions or thoughts clearly, making it essential for the nurse to ask open-ended questions and use empathetic listening techniques.
Example: A nurse might document, “Patient reports feeling ‘empty’ and describes persistent feelings of hopelessness. States that sleep has been irregular, and they often feel tired during the day.”
Tip: Record direct quotes whenever possible to preserve the authenticity of the patient’s self-expression. Ask questions about mood, sleep patterns, appetite, and social interactions to gain insight into the patient’s mental health status.

In psychiatric nursing, understanding the patient’s subjective experience helps create a foundation for empathetic, individualized care and improves communication across the mental health team.

2. Objective (O): Documenting Observed Behavior and Physical Indicators

The Objective section in psychiatric SOAP notes focuses on measurable or observable information, including the patient’s behavior, appearance, and physiological indicators that may correlate with their mental health status.

Consideration: Psychiatric nurses should document physical signs of mental distress, such as rapid speech, poor eye contact, restlessness, or hygiene concerns, as well as any physical symptoms related to mental health, such as weight changes or fatigue.
Example: “Patient appears disheveled, with unkempt hair and clothing. Speech is slow, and responses are delayed. Mild tremors noted in hands. No eye contact.”
Tip: Use specific language to describe observed behaviors. Avoid vague terms like “upset” and instead document specific behaviors, such as “tearful” or “fidgeting,” which give a clearer picture of the patient’s state.

By accurately recording objective observations, nurses can provide critical information that informs diagnosis, tracks symptom progress, and supports the effectiveness of care plans.

3. Assessment (A): Analyzing Mental Health Status and Diagnosing Symptoms

In the Assessment section, psychiatric nurses synthesize the subjective and objective information to determine the patient’s mental health status, identify potential diagnoses, and evaluate symptom severity.

Consideration: This section should capture the nurse’s clinical judgment based on both verbal and non-verbal cues. In psychiatric care, assessments often include determining risk factors such as suicidal ideation, mood instability, and cognitive functioning.
Example: “Patient exhibits signs of major depressive disorder, including persistent sadness, anhedonia, low energy, and impaired concentration. Moderate risk of self-harm based on reported hopelessness and withdrawal from social activities.”
Tip: Utilize standardized assessment tools, such as the PHQ-9 for depression or the GAD-7 for anxiety, to support objective scoring and enhance diagnostic accuracy.

By using validated assessment tools and clinical judgment, psychiatric nurses can create a detailed evaluation of the patient’s mental health, providing a foundation for targeted care plans.

4. Plan (P): Developing Individualized Interventions and Follow-Up Care

The Plan section should outline the interventions, therapies, and follow-up care that will address the patient’s specific mental health needs. In psychiatric nursing, the plan often includes safety measures, therapy recommendations, and supportive resources for ongoing mental health management.

Consideration: Care plans should be individualized to meet the patient’s unique needs and goals. The plan may involve psychotherapy, medication management, safety monitoring, and family education. In cases with high risk, the plan should prioritize safety interventions, such as suicide precautions.
Example: “Initiate a safety contract with the patient and provide 1:1 supervision due to moderate risk of self-harm. Schedule daily check-ins to monitor mood and energy levels. Encourage participation in group therapy for social support and coping skills.”
Tip: Include specific short-term and long-term goals, and ensure that caregivers and family members understand their role in the plan. Document any referrals to mental health specialists or community resources.

In psychiatric nursing, a well-defined plan supports continuity of care, helping the healthcare team track the patient’s progress, adjust interventions as needed, and provide support for caregivers.

Case Example of a Psychiatric SOAP Note

Patient Overview: A 30-year-old female with a history of anxiety and depression presents with increased mood swings, insomnia, and feelings of isolation. She denies any recent physical illness.

Psychiatric SOAP Note Example

Subjective:
- Patient states she has been “feeling very down” and “unable to keep up with normal tasks.” Reports difficulty sleeping and describes feeling “overwhelmed” and “like a burden” to her family. Denies suicidal thoughts but admits to occasional thoughts of “wanting to disappear.”
Objective:
- Appears fatigued, with dark circles under her eyes. Speech is slow, with frequent pauses. Body posture is slouched, and she avoids eye contact. Presents with mild agitation, fidgeting with her hands during the interview.
Assessment:
- Symptoms consistent with major depressive disorder, with moderate levels of anxiety. Insomnia and self-reported feelings of burden suggest risk of worsening mental health without intervention. Currently denies active suicidal ideation but reports a lack of self-worth.
Plan:
- Schedule daily mental health check-ins and recommend a cognitive behavioral therapy (CBT) session. Encourage engagement in social support groups. Begin low-dose antidepressant therapy as prescribed by the psychiatrist. Educate the patient on relaxation techniques to improve sleep, and provide a follow-up visit in one week to assess medication effects and symptom progression.

Best Practices for Psychiatric SOAP Notes in Nursing

When documenting SOAP notes for psychiatric nursing, consider the following best practices to ensure comprehensive and effective mental health documentation:

Prioritize Empathy and Clarity in Subjective Documentation: Use the patient’s own words wherever possible to capture their experience accurately. Open-ended questions are essential for gathering meaningful insights into their mental state.
Be Specific with Behavioral Observations: Document exact behaviors and physical indicators in the Objective section to provide a clear picture of the patient’s condition and any noticeable changes.
Utilize Standardized Mental Health Assessment Tools: Tools like the PHQ-9 or the GAD-7 provide objective data to support assessments, helping track symptom severity over time.
Individualize Care Plans: Every patient’s mental health needs are different. Design plans that address their specific symptoms, safety needs, and coping skills.
Ensure Follow-Up and Monitoring: Consistent follow-up is critical in psychiatric care. Document check-ins and progress to evaluate the effectiveness of interventions and adjust the plan as needed.

Effective Mental Health Documentation with Psychiatric SOAP Notes

SOAP notes for psychiatric nursing serve as a valuable tool in mental health care, helping nurses capture detailed patient information, create accurate assessments, and develop individualized care plans. By documenting each element thoroughly and empathetically, psychiatric nurses can provide comprehensive, patient-centered care that addresses both immediate and long-term mental health needs.

In psychiatric nursing, precise and compassionate documentation in SOAP notes supports improved patient outcomes, fosters continuity of care, and helps build trust between patients and healthcare provide