Writing high-quality SOAP notes is a core part of psychiatric care. These notes help you track clinical reasoning, improve communication with other providers, and ensure compliance. But they’re also time-consuming—unless you’re using S10.ai.
S10.ai is an AI-powered medical scribe that writes psychiatry SOAP notes for you—in real-time, with zero manual typing. This guide walks you through each section and shows how S10.ai simplifies the process.
The Subjective section captures what the patient shares—how they feel, what they’re experiencing, and the context behind it. With S10.ai, this is recorded live, accurately, and directly into your preferred EHR template.
What to include:
Chief complaint
History of present illness
Symptom description (frequency, intensity, impact)
Past psychiatric and medical history
Medication use
Substance use
Social background
Treatment goals
Any other context relevant to care
Sample Subjective Section:
The patient presents with a chief complaint of extreme anxiety and inability to sleep for the past month. The anxiety began after a stressful event at work and has been worsening over the past few weeks. The patient reports feeling anxious most of the day, with frequent panic attacks and difficulty concentrating.
The patient has a history of depression and was treated with antidepressants five years ago. The patient also has a history of hypothyroidism, which is currently well-managed with levothyroxine 75mcg daily.
The patient reports occasional alcohol use and no use of illicit drugs. Socially, the patient lives alone, works as a software engineer, and has a supportive network of friends.
The patient’s goal is to reduce anxiety and improve sleep quality. Additionally, the patient reports increased anxiety when thinking about work deadlines.
S10.ai tip: Because S10 captures the conversation as it happens, it picks up phrasing in the patient’s own words—making this section more accurate and empathetic.
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This section is where you log observable findings: what you see, measure, or test. S10.ai helps document standardized MSEs (Mental Status Exams) and pulls in vitals, labs, or behavioral cues when relevant.
What to include:
Mental Status Exam (MSE)
Vital signs
Physical exam notes
Behavioral observations
Test results
Sample Objective Section:
Mental Status Examination (MSE): The patient appears well-groomed, with normal speech and a cooperative attitude. Mood is anxious, affect is congruent. Thought process is logical, and thought content is free of delusions or hallucinations. Cognition is intact, insight and judgment are fair.
Vital Signs: BP 120/80, HR 72, RR 16, Temp 98.6°F
Physical Examination Findings: No significant abnormalities noted on physical examination.
Behavioral Observations: The patient fidgeted frequently and avoided eye contact when discussing work-related stress.
Diagnostic Tests: Thyroid function tests within normal limits.
S10.ai tip: Structured fields for MSE and auto-integration of lab values speed up this part significantly.
Related resource:
This is your clinical interpretation. You take everything the patient says and what you observe, and distill it into a clear diagnosis, clinical impression, functional impact, and prognosis.
What to include:
Primary diagnosis
Clinical reasoning/impression
Functional limitations
Progress since last visit
Short-term and long-term goals
Prognosis
Sample Assessment Section:
The patient is diagnosed with Generalized Anxiety Disorder (GAD). The clinical impression indicates that the patient’s symptoms are consistent with this diagnosis, exacerbated by work-related stress.
Functionally, the patient has significant difficulty concentrating at work and experiences frequent panic attacks. Since the last visit, the patient reports a slight improvement in sleep quality but continues to experience high levels of anxiety.
The prognosis is positive, with the expectation that appropriate treatment will enable the patient to manage anxiety and improve overall functioning.
The short-term goal is to reduce anxiety levels to a manageable level within four weeks. The long-term goal is to improve sleep quality and concentration at work within three months.
S10.ai tip: AI assistance can auto-suggest ICD-10 codes and flag symptom patterns—helping you move from note to billing faster.
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Lay out what happens next—therapy, meds, follow-up, and lifestyle guidance. The plan should be actionable and customized to the patient’s needs.
What to include:
Treatment strategy (therapy, modalities)
Medications prescribed or adjusted
Patient education
Lifestyle changes
Follow-up schedule
Sample Plan Section:
The treatment plan for the patient involves several key components to address their Generalized Anxiety Disorder (GAD). The primary focus will be on initiating cognitive-behavioral therapy (CBT) to address anxiety symptoms. Additionally, the patient will be prescribed sertraline 50mg daily for anxiety.
Therapeutic interventions will include weekly individual therapy sessions. Patient education will focus on relaxation techniques and the importance of sleep hygiene.
Lifestyle modifications will be recommended, including regular physical activity and a balanced diet.
Follow-up appointments will be scheduled in two weeks to assess the patient’s response to medication and therapy.
S10.ai tip: Once the plan is documented, you can instantly generate a printable summary or EHR update—saving minutes per visit.
Also read:
What this really means is: SOAP notes don’t need to be a time-suck. With S10.ai, psychiatry notes can be completed while you’re still talking to the patient. No backlogs, no burnout, no compromises on quality.
Start with 3 free SOAP notes. No credit card required.
Visit s10.ai to try it.
1) What is a SOAP note in psychiatry?
A SOAP note in psychiatry is a structured clinical document that includes Subjective, Objective, Assessment, and Plan sections. It helps psychiatrists document patient symptoms, observations, diagnoses, and treatment plans clearly and consistently.
2) How does S10.ai help with writing psychiatry SOAP notes?
S10.ai is an AI-powered medical scribe that listens during your session and automatically generates psychiatry SOAP notes in real time. It captures subjective details, populates MSE templates, suggests ICD-10 codes, and formats everything according to your EHR preferences.
3) What should be included in a psychiatry SOAP note?
A psychiatry SOAP note should include the patient’s self-reported symptoms, mental status exam findings, diagnosis or clinical impression, and a personalized treatment plan. This includes therapy recommendations, medications, and follow-up steps.
4) Can S10.ai generate SOAP notes for mental health professionals?
Yes. S10.ai is built for mental health providers including psychiatrists, therapists, and psychiatric nurse practitioners. It auto-generates SOAP notes based on live conversations and adapts to psychiatric workflows and language.
5) Are there psychiatry SOAP note templates available with S10.ai?
Yes. S10.ai includes specialty-specific templates for psychiatry SOAP notes, which can be customized to match your workflow. These templates cover all key components such as MSE, diagnostic impressions, treatment plans, and follow-ups.
6) How accurate are SOAP notes generated by S10.ai?
S10.ai uses advanced medical language models trained on specialty-specific terminology, including psychiatric conditions. It ensures high accuracy in capturing clinical conversations and structuring SOAP notes for compliance and clarity.
7) Can S10.ai handle psychiatric terminology and abbreviations?
Absolutely. S10.ai is designed to understand and correctly apply psychiatric terms, including acronyms like GAD, MSE, CBT, and more. It also tailors phrasing and formatting to meet clinical documentation standards in psychiatry.
8) Is it safe to use AI for psychiatric note-taking?
Yes. S10.ai uses HIPAA-compliant, secure architecture to protect patient data. It allows clinicians to maintain full control over their notes while benefiting from automation that reduces burnout and increases productivity.
9) How can I start using S10.ai for psychiatry SOAP notes?
You can get started with S10.ai for free and generate up to 3 SOAP notes without a credit card. Just visit https://s10.ai and select the psychiatry specialty to begin.
10) Does using S10.ai reduce documentation time for psychiatrists?
Yes. Psychiatrists using S10.ai report significantly less time spent on documentation, with many completing their notes during or immediately after the session—freeing up time for more patients or reducing after-hours charting.
How do I write effective SOAP notes in psychiatry to improve patient care?
Writing effective SOAP notes in psychiatry involves a structured approach to ensure comprehensive documentation. Start with the Subjective section, where you record the patient's reported symptoms and concerns. In the Objective section, include observable data such as mental status examination findings. The Assessment section should provide a clinical interpretation of the subjective and objective information, leading to a diagnosis or differential diagnosis. Finally, the Plan section outlines the treatment strategy, including medication, therapy, and follow-up appointments. Mastering SOAP notes can enhance communication with colleagues and improve patient outcomes by providing clear, organized documentation.
What are common mistakes to avoid when writing psychiatric SOAP notes?
Common mistakes in writing psychiatric SOAP notes include being too vague or overly detailed, which can obscure critical information. Avoid using jargon or abbreviations that might not be universally understood. Ensure that the Subjective section accurately reflects the patient's words and that the Objective section is based on observable facts. In the Assessment, refrain from making unsupported conclusions, and in the Plan, provide clear, actionable steps. By avoiding these pitfalls, you can create SOAP notes that are both precise and useful for ongoing patient care.
Why is it important to use SOAP notes in psychiatric practice?
SOAP notes are crucial in psychiatric practice because they provide a standardized method for documenting patient interactions, which enhances continuity of care. They help clinicians organize their thoughts and ensure that all aspects of the patient's condition are considered. SOAP notes facilitate communication among healthcare providers, making it easier to track patient progress and adjust treatment plans as needed. By adopting SOAP notes, clinicians can improve the quality of care and ensure that all team members are informed and aligned in their approach to patient management.
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