SOAP note examples › Psychiatry

Psychiatric SOAP Note Example: Panic Disorder, Initial Evaluation

A psychiatric intake note: the patient's own words, a documented safety assessment, substance use, and a full mental status exam in the Objective.

By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026

Setting: Outpatient psychiatric evaluationPatient: Fictional patient: 31-year-old woman

SSubjective

Chief complaint
"I keep having these attacks where I think I'm dying."
HPI
4 months of sudden episodes, 2-3 a week, of racing heart, chest tightness, shortness of breath, tingling hands and fear of dying. They peak within 10 minutes and resolve within 30. Two ED visits with normal ECG and troponin each time (records reviewed). Constant worry about the next attack; now avoids freeway driving and crowded stores. Began after a job change. Falls asleep late because of worry, about 6 hours a night. Appetite normal; energy fair; concentration reduced at work. Missed 3 days of work this month. Denies persistent low mood or loss of interest.
Safety
Denies suicidal ideation (passive or active), plan, intent or past attempts. Denies homicidal ideation. No firearms in the home.
Psychiatric history
No prior diagnoses, hospitalizations or psychiatric medications.
Substance use
3-4 cups of coffee plus one energy drink a day. Alcohol 1-2 drinks a week. No cannabis, nicotine or other drugs.
Social
Lives with a supportive partner. Works as an accountant. No legal issues. Family history: mother with anxiety.
Collateral
None today; patient agreed to the partner joining the next visit.

OObjective

Vital signs
BP 122/78, HR 88, RR 14, BMI 23.
Mental status exam
Appearance: well groomed, appropriately dressed.
Behavior: cooperative, good eye contact, restless leg movement.
Speech: normal rate, volume and prosody.
Mood: "anxious all the time."
Affect: anxious, congruent, full range.
Thought process: linear and goal-directed.
Thought content: preoccupied with fear of future attacks; no suicidal or homicidal ideation, delusions or obsessions.
Perception: no hallucinations.
Cognition: alert, oriented to person, place, time and situation; attention intact.
Insight and judgment: good.
Screening scores
GAD-7: 12. PHQ-9: 6. TSH last week: 1.8 (normal).

AAssessment

Diagnosis
Panic disorder: recurrent unexpected panic attacks with more than a month of persistent worry about further attacks and avoidance. Medical causes reasonably excluded (normal ECG and troponin twice, normal TSH); heavy caffeine use may be contributing.
Differential: generalized anxiety disorder (worry centers on the attacks rather than many areas), hyperthyroidism (TSH normal), arrhythmia (normal ECGs; consider ambulatory monitoring if the episodes change), substance-induced anxiety (caffeine, addressed below). Avoidance does not yet meet criteria for agoraphobia.
Risk assessment
Risk factors: anxiety disorder, recent stressor. Protective factors: supportive partner, employment, help-seeking, future-oriented, no firearm access, no substance use disorder. Overall acute risk: low.

PPlan

Safety plan
Reviewed warning signs and coping steps; crisis resource given (988 Suicide & Crisis Lifeline).
Medications
Start sertraline 25 mg daily for 7 days, then 50 mg daily. Counseled: full effect takes 4-6 weeks; possible early jitteriness, nausea and sexual side effects; call for any worsening mood or suicidal thoughts. No benzodiazepine.
Therapy / referrals
Referral for cognitive behavioral therapy focused on panic, including interoceptive exposure. Taught slow-breathing technique. Reduce caffeine to 1 cup a day or less; stop energy drinks.
Follow-up
2 weeks to check tolerability, then every 4 weeks. Call 988 or go to the ED for thoughts of self-harm.

Fictional patient, written for learning. Follow your program's and facility's documentation standards.

Why this note works

What students often miss

Psychiatry SOAP note template

The history is the patient's story; the exam is the mental status exam; safety comes first.

SSubjective

Chief complaint
In the patient's words.
HPI
Symptoms, duration, stressors, sleep, appetite, energy, concentration, function.
Safety
Suicidal/homicidal ideation, plan, intent, means, prior attempts.
Psychiatric history
Diagnoses, hospitalizations, medications tried.
Substance use
 
Social
Supports, housing, work, legal, access to weapons.
Collateral
Name the source.

OObjective

Vital signs
 
Mental status exam
Appearance, behavior, speech, mood (patient's words), affect, thought process, thought content, perception, cognition, insight, judgment.
Screening scores
With the tool named.

AAssessment

Diagnosis
With supporting criteria.
Risk assessment
Risk factors, protective factors, overall level.

PPlan

Safety plan
 
Medications
Changes and monitoring.
Therapy / referrals
 
Follow-up
Interval; crisis resources given.
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