Mental Health SOAP Notes: Psychology Templates & AI Examples

Mental health SOAP notes carry a specific weight that medical and allied health notes don’t. They document not just what happened in the room, but a person’s inner experience, risk status, therapeutic progress, and clinical reasoning in one of the most sensitive areas of healthcare.

Done well, a psychology progress note protects the patient, protects the clinician, and creates a treatment record that actually reflects what’s happening. This guide covers what belongs in each section, with real examples for a psychologist’s Better Access session and a psychiatrist’s outpatient review.

How Mental Health SOAP Notes Differ

The core structure — Subjective, Objective, Assessment, Plan — is the same. But the content changes significantly in mental health contexts:

• Subjective captures mood, affect, reported symptoms, functional impact, and the patient’s own language around their experience, including updates since the last session.
• Objective is a Mental State Examination (MSE) — appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, and judgment. There are no vital signs or physical examination findings in most outpatient psychology sessions.
• Assessment documents formulation, diagnosis, risk, and progress against treatment goals. For Better Access sessions, this links to the Mental Health Treatment Plan.
• Plan includes session focus, therapeutic interventions, homework tasks, next session goals, and any risk management steps.

Psychology SOAP Notes: Better Access Session Example

Session: Session 4 of 10 — Generalised Anxiety Disorder, Better Access Mental Health Treatment Plan

S — Subjective

Patient reports moderate improvement in overall anxiety since commencing CBT three weeks ago. Sleep remains disrupted — waking 2–3 times per night, difficulty returning to sleep. Identifies work as primary stressor: performance review scheduled next week is triggering avoidance behaviour (two sick days this week). Self-rates anxiety 5/10, down from 8/10 at intake. Completed thought records between sessions — found cognitive restructuring around catastrophising useful but struggled to apply in high-stress moments.

O — Objective (Mental State Examination)

Appearance: well-groomed, appropriate dress
Behaviour: cooperative, mild psychomotor tension
Speech: normal rate, volume, coherence
Mood: “anxious but managing” — affect mildly anxious, congruent
Thought form: goal-directed · Thought content: ruminative cognitions re: work performance, no suicidal ideation, no self-harm
Perception: no hallucinations reported
Cognition: grossly intact · Insight: good · Judgment: intact
PHQ-9: 7 (down from 11 at intake) · GAD-7: 12 (down from 17 at intake)

A — Assessment

GAD responding to CBT — clinically meaningful reduction in GAD-7 (−5) and PHQ-9 (−4) since intake. Avoidance behaviour (sick leave) remains the primary treatment target. Sleep disturbance secondary to anxiety, not an independent disorder at this stage. No risk concerns. On track within the 10-session Better Access plan.

P — Plan

1. Session focus: behavioural activation; introduce graded exposure hierarchy for work-related avoidance
2. Sleep hygiene psychoeducation — provide written handout
3. Prepare cognitive coping script for upcoming performance review
4. Homework: complete exposure hierarchy draft; continue thought records daily; implement one sleep hygiene strategy this week
5. Next session in 1 week
6. Re-administer PHQ-9 and GAD-7 at Session 6 · Prepare GP review letter if indicated

Psychiatry SOAP Notes: Outpatient Review Example

Presenting complaint: Outpatient review — Bipolar I Disorder, maintenance phase

S — Subjective

38-year-old female, known Bipolar I, last hypomanic episode 14 months ago, currently euthymic. Reports stable mood, sleeping 7–8 hours, appetite normal. No recent stressors. Returned to part-time work 3 months ago — tolerating well. Medication adherent (lithium 1000mg nocte + quetiapine 50mg nocte). Notes mild intermittent tremor, worse in the morning. No suicidal ideation. Maintaining social connections.

O — Objective (Mental State Examination)

Appearance: well-groomed, appropriate
Behaviour: engaged, calm
Speech: normal rate and volume
Mood: “pretty good” — affect euthymic, full range, appropriate
Thought form: logical and goal-directed · Thought content: no suicidal ideation, no grandiosity, no paranoia
Perception: no hallucinations · Cognition: grossly intact
Insight: good — demonstrates understanding of early warning signs
Lithium level (last week): 0.72 mmol/L (therapeutic range 0.6–0.8 maintenance)
TFTs: normal · eGFR: 74 (mild reduction, stable over 2 years)

A — Assessment

Bipolar I, well-maintained in euthymia on current regimen. Lithium level therapeutic. Renal function mildly reduced but stable — annual monitoring appropriate. Tremor likely lithium-related; assess impact on quality of life before dose adjustment. Return to part-time work is a positive functional indicator. No current risk concerns.

P — Plan

1. Continue lithium 1000mg nocte + quetiapine 50mg nocte — no changes
2. Assess tremor severity — if affecting quality of life, consider low-dose propranolol trial
3. Annual lithium level, TFTs, eGFR due in 3 months — send reminder
4. Early warning signs review — patient to identify two early hypomanic indicators to monitor
5. Written relapse prevention plan updated today — copy to GP
6. Next review in 3 months

Better Access Documentation Requirements

For psychologists providing services under the Better Access initiative, session notes must support the Medicare claim and align with the Mental Health Treatment Plan from the referring GP or psychiatrist. Your notes should document:

• That the session occurred within the referral period
• The therapeutic modality used (CBT, ACT, Schema Therapy, DBT, etc.)
• Progress against the treatment goals in the MHTP
• Any risk assessment or safety planning that occurred
• The session number in the current referral cycle (1–10)

At Session 6, prepare a progress summary for the GP — most GPs use this to determine whether to issue a second Mental Health Treatment Plan for Sessions 7–10.

Privacy and Consent in Mental Health Notes

Mental health records carry additional sensitivity under the Privacy Act 1988. AI-generated mental health notes require patient consent at the start of each session — inform the patient the AI scribe will listen, document consent in the record, and give them a genuine right to decline without affecting their care.

NirvaScribe does not retain audio after processing and does not use session content for model training. Notes remain under the clinician’s control at all times.

How NirvaScribe Handles Mental Health Notes

NirvaScribe’s Mental Health SOAP Notes template is available for psychologists, clinical psychologists, psychiatrists, counsellors, psychotherapists, and social workers in mental health settings. The AI listens to the session and drafts an MSE-structured Objective section from clinical observations, a Subjective section from the patient’s reported experience, and an Assessment and Plan from the clinician’s closing formulation.

The template supports Better Access documentation, NDIS psychology reporting, and outpatient psychiatric reviews. The clinician reviews, adjusts anything that doesn’t capture clinical nuance, and signs off.

Sign up for free here - app.nirvascribe.com/register

All clinical examples are fictional and created for illustrative purposes only.