What Makes SOAP Notes Support Medical Necessity

Medical necessity isn't about long notes. It's about the right signal presented clearly.

In psychiatry, strong SOAP notes connect today's complaints and observations to an assessment that justifies your plan and follow-up. The result should be readable to another clinician, defensible to an auditor, and easy for you to reuse at the next visit.

A good compass is the APA's record-keeping guidance, which emphasizes clarity, continuity, and appropriateness of detail. See APA Record-Keeping Guidelines. Aim for sufficiency, not verbosity.

Subjective

Capture the patient's words and relevant context: interval change since last visit, medication adherence, side effects, function at work/school/home, and safety concerns. Avoid filler like "patient doing ok." Be specific and comparable visit to visit.

Objective

Include mental status exam (appearance, behavior, speech, mood/affect, thought process/content, cognition, insight/judgment), vitals if taken, and standardized scales when used.

If you use PHQ-9 or GAD-7, include:

• Total score
• Severity band
• Item #9 status
• Change from prior

Link to credible references when training staff on scale use. NIMH's medication overview is a good companion for patient education: NIMH: Mental Health Medications.

Assessment

This is where medical decision-making lives. State diagnoses (new or established), progress toward goals, differential, risk, and how data informed your conclusions. Tie symptoms and scales to function. Document why you are continuing, changing, or stopping treatment.

Plan

Spell out medications/therapy, labs or monitoring, education given, follow-up interval, and contingencies. For example: "If activation persists beyond 72 hours, message clinic."

For security and privacy, ensure your EHR and tools adhere to HIPAA expectations. HHS's summary of the Security Rule is a concise reference: HHS Summary of the HIPAA Security Rule.

These anchors keep your SOAP notes clinically tight and audit-ready without ballooning in length.

Psychiatry SOAP Note Examples for Med Management

Here are condensed psychiatry SOAP examples you can adapt.

Example 1: Depression Follow-Up With Partial Response

Subjective: "Energy is better; still waking 3 to 4 a.m." Works full-time. Missed two doses this week. No SI. PHQ-9 = 11 (was 15), item #9 = 0. Side effects: mild nausea first week, now resolved.

Objective: MSE: cooperative, tearful at times; speech normal; mood "tired"; affect constricted; TP linear; TC no SI/HI/AVH; I/J fair. Vitals WNL.

Assessment: MDD, recurrent, moderate. Partial response to SSRI with residual insomnia and anergia. No acute safety concerns.

Plan: Increase SSRI 20 to 30 mg daily. Sleep hygiene review. Consider CBT-I resources. Follow-up 3 to 4 weeks. Contingency: if activating, reduce to 20 mg and message. Education on black-box warning provided. See medication education guide at NIMH: Mental Health Medications.

Example 2: Generalized Anxiety With Therapy Focus

Subjective: "Worry spirals most evenings." GAD-7 = 14 (was 13). No panic attacks. Using skills inconsistently.

Objective: MSE: anxious but engaged; no psychosis; cognition intact. Last PHQ-9 = 8.

Assessment: GAD, persistent. Psychotherapy primary. Consider SSRI augmentation if no improvement.

Plan: Intensify CBT with exposure hierarchy. Skills practice 10 min nightly. No med changes. Follow-up 2 weeks. Provide handouts.

Example 3: ADHD Med Check With Appetite Concerns

Subjective: Focus improved. Appetite lower at lunch. Weight stable. Sleeps 7 hours. No palpitations.

Objective: BP/HR WNL. MSE unremarkable. Work performance improved per supervisor email.

Assessment: ADHD, combined type. Good response. Mild appetite suppression.

Plan: Continue dose. Add protein breakfast. Monitor weight. Follow-up 1 month. Consider long-acting switch if appetite worsens.

Each example shows necessity through trajectory, function, and risk assessment, then a plan with monitoring. Copy the skeleton, change the specifics, and you have a fast, defensible note.

How to Turn These Examples Into Faster Workflows

Turn examples into routine by standardizing a compact SOAP structure, integrating scales, and automating the longitudinal story.

Make the Structure Predictable

• Subjective: Checkboxes for interval change, adherence, side effects, function, safety
• Objective: Quick-pick MSE with free-text nuance
• Assessment: Prompts for differential and risk
• Plan: Blocks for meds (dose, start date, monitoring), therapy, education, follow-up, contingencies

Embed Best Practices Where They Help

• Surface the last 3 to 6 months of PHQ-9/GAD-7 trends next to the note composer
• Pre-fill med names with generic/brand, dose, and last change date
• Auto-insert scale interpretation text with severity bands and change from prior

Train With Real References

Train your team so everyone speaks the same language. The APA record-keeping page offers principles for sufficiency and clarity. Pair with internal playbooks on documenting medical decision-making and with HIPAA Security Rule summaries for privacy guardrails.

Measure Outcomes

Track these metrics to ensure your workflow is working:

• Time to sign
• Denial rates citing documentation
• Addenda per note
• Clinician after-hours minutes

With compact SOAP patterns, psychiatrists and PMHNPs finish notes in-session, preserve narrative quality, and maintain audit-ready clarity.

FAQs About Psychiatry SOAP Notes

What should be included in the Subjective section of a psychiatric SOAP note?

The Subjective section should include the patient's own words, interval change since last visit, medication adherence, side effects, functional status at work/school/home, and any safety concerns. Avoid vague filler and be specific enough to compare across visits.

How do you document PHQ-9 and GAD-7 scores in SOAP notes?

Include the total score, severity band, item #9 status (for PHQ-9), and change from the prior visit. This creates a measurable trajectory that supports medical necessity.

What makes a psychiatry SOAP note audit-ready?

An audit-ready note connects complaints and observations to an assessment that justifies the plan. It should be readable by another clinician, defensible to an auditor, and structured for easy reuse at subsequent visits.

How long should a psychiatric SOAP note be?

Aim for sufficiency, not verbosity. A good psychiatry SOAP note includes all required elements to demonstrate medical necessity without unnecessary padding. The APA emphasizes clarity, continuity, and appropriate detail.