Study Notes: Focused SOAP Note for Anxiety, PTSD, and OCD
Introduction
A Focused SOAP Note is a structured documentation method used by healthcare professionals to record patient encounters. SOAP stands for Subjective, Objective, Assessment, and Plan. This format is particularly useful in mental health settings to track symptoms, diagnosis, and treatment progress for conditions like Anxiety, Post-Traumatic Stress Disorder (PTSD), and Obsessive-Compulsive Disorder (OCD).
🧠 Overview of Conditions
Anxiety
Anxiety disorders involve excessive fear or worry that interferes with daily functioning. Common types include Generalized Anxiety Disorder (GAD), Panic Disorder, and Social Anxiety Disorder.
Symptoms:
Restlessness
Fatigue
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbances
PTSD
PTSD is a trauma-related disorder that develops after exposure to a traumatic event such as violence, natural disasters, or accidents.
Symptoms:
Intrusive memories
Flashbacks
Nightmares
Avoidance of trauma-related stimuli
Hyperarousal (e.g., exaggerated startle response)
Negative changes in mood and cognition
OCD
OCD is characterized by persistent, unwanted thoughts (obsessions) and repetitive behaviors (compulsions) performed to reduce anxiety.
Symptoms:
Obsessions: contamination fears, symmetry, intrusive thoughts
Compulsions: handwashing, checking, counting
Significant distress or impairment
📝 SOAP Note Format
S – Subjective
This section captures the patient’s own words and reported symptoms.
Example for Anxiety:
“I feel nervous all the time, especially in social situations. I can’t sleep well and my heart races even when I’m just thinking about going out.”
Example for PTSD:
“I keep having nightmares about the accident. Loud noises make me jump, and I avoid driving altogether.”
Example for OCD:
“I wash my hands at least 30 times a day. I know it’s excessive, but I feel dirty otherwise.”
Include:
Chief complaint
History of present illness
Past psychiatric history
Family history
Social history
Substance use
Review of systems (psychological focus)
O – Objective
This section includes observable data and clinical findings.
Mental Status Exam (MSE):
Appearance: Clean, disheveled, anxious
Behavior: Fidgety, hypervigilant
Mood: “Anxious,” “Fearful”
Affect: Restricted, labile
Thought process: Logical, goal-directed
Thought content: Obsessions, flashbacks
Insight/Judgment: Fair to poor
Speech: Normal rate and tone
Cognition: Alert, oriented x3
Vitals:
BP: Elevated in anxiety
HR: Tachycardia
RR: Increased
Sleep pattern: Disturbed
A – Assessment
This section includes diagnostic impressions and clinical reasoning.
Example:
Anxiety Disorder, moderate severity
PTSD, chronic
OCD, severe
Use DSM-5 criteria to support diagnosis. Include differential diagnoses and rule-outs.
Tools:
GAD-7 for anxiety
PCL-5 for PTSD
Y-BOCS for OCD
P – Plan
This section outlines the treatment strategy.
Pharmacologic:
SSRIs (e.g., sertraline, fluoxetine)
Benzodiazepines (short-term use for anxiety)
Antipsychotics (adjunct for severe OCD)
Psychotherapy:
Cognitive Behavioral Therapy (CBT)
Exposure Therapy (PTSD, OCD)
EMDR (PTSD)
Acceptance and Commitment Therapy (ACT)
Lifestyle:
Sleep hygiene
Exercise
Mindfulness and relaxation techniques
Follow-up:
Weekly therapy sessions
Medication review in 4 weeks
Safety planning if suicidal ideation is present
🧑⚕️ Case Example: Dev CORDOBA
Subjective: Dev, a 28-year-old male, reports persistent anxiety, intrusive thoughts, and avoidance behaviors following a car accident 2 years ago. He describes compulsive handwashing and difficulty sleeping.
Objective: Dev appears anxious, avoids eye contact, and exhibits compulsive behaviors during the interview. MSE reveals hypervigilance, restricted affect, and poor insight.
Assessment:
PTSD, moderate
OCD, severe
Rule out Panic Disorder
Plan:
Initiate fluoxetine 20 mg daily
Begin CBT with exposure and response prevention
Schedule EMDR sessions
Encourage journaling and mindfulness
Follow-up in 2 weeks
🧪 Diagnostic Tools Summary
Tool Purpose Scoring
GAD-7 Screens for anxiety 0–21
PCL-5 PTSD checklist 0–80
Y-BOCS OCD severity 0–40
📌 Key Takeaways
SOAP notes provide a structured way to document mental health encounters.
Anxiety, PTSD, and OCD have overlapping but distinct features.
Accurate diagnosis requires both subjective reporting and objective observation.
Treatment includes medication, therapy, and lifestyle changes.
Regular follow-up and reassessment are essential for progress.