SOAPNoteExample.pdf
- First Name: Lucy
- Last Name: Nells
- Date of Birth: 16/05/1994
- Date: 20/11/2022
- Subjective: Lucy states that she has improved with her aggressive thoughts, stating that “I feel like I don’t think about harming others as much.” She explains that she is far more comfortable with recognizing these patterns, and that “Usually when I feel that way, I will go exercise which helps me overcome the obsession.”
- Objective: Lucy appears at ease, and calmer than previous sessions. She has a relaxed posture, and her journal entries are much lighter in tone. Physically, she looks healthy, which is likely a result of the increased exercise. Lucy reports good sleeping and eating habits, and presents improvement in regards to her OCD and obsessive thoughts with a fewer number.
- Assessment: Lucy has mild to moderate OCD and has been seeing me for multiple sessions. She demonstrates improvement of managing her thoughts, and with her cognitive behavioural techniques, she presents significantly less distress. Lucy will continue to work on this to see further improvements, and continue with her journaling and exercises.
- Plan: No medication is needed for Lucy. She will see me in 2 weeks on the 14th of November, and discussion will be had concerning sessions occurring monthly instead of weekly.
Nicky333
