Complete Guide to Depression SOAP Note Examples for Healthcare Providers

If you've ever struggled to document mental health visits in a way that meets insurance requirements while capturing the nuances of depression, this guide is for you.

I've talked to countless primary care physicians, psychiatrists, therapists, and psychiatric nurse practitioners who spend hours documenting mental health visits, trying to justify medication changes, therapy referrals, and ongoing treatment.

The reality is that depression documentation has specific requirements that insurance companies scrutinize carefully.

They want to see clear assessment of symptom severity, documentation of functional impairment, evidence of treatment response, and proof that interventions are medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on providing quality mental health care.

In this article, I'll show you exactly how to write depression SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for Depression Treatment)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for mental health patients.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For depression specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of symptom severity and functional impairment
• Appropriate screening using validated instruments (PHQ-9, GAD-7)
• Evidence of treatment response or need for adjustment
• Medical necessity for medications, therapy, or specialist referrals
• Safety assessment and suicide risk evaluation
• Patient response to interventions over time

SOAP stands for:

• S — Subjective: What the patient reports about mood, sleep, energy, appetite, concentration, anhedonia, suicidal ideation, and functional impact.
• O — Objective: Your clinical findings including mental status exam, appearance, affect, behavior, PHQ-9 scores, and any relevant physical findings.
• A — Assessment: Your clinical diagnosis with severity level, risk assessment, treatment response, and evaluation of current functioning.
• P — Plan: Your treatment plan including medication management, therapy referrals, follow-up timing, safety planning, and patient education.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies ongoing treatment and interventions.

How You Can Approach Depression SOAP Notes

There's no single correct method for writing depression SOAP notes, but some approaches work better than others depending on your practice.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and capturing the nuances of mental status and patient narrative can be difficult when you're rushing through documentation.

2. SOAP Notes Doctor

You record your session observations or dictate key findings, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for in mental health documentation.

How to Make Depression SOAP Notes Faster

One of the biggest complaints I hear from providers treating depression is how documentation eats into their already limited time.

You've just finished a full day of appointments, each requiring careful assessment of mood, safety evaluation, and treatment planning, and instead of taking a mental break or preparing for tomorrow's patients, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials for medication approvals or therapy authorization; make them too detailed and you've just added hours to your day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your session findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"PHQ-9 score 18, patient reports persistent low mood, sleep 4-5 hours nightly, anhedonia marked, denies SI/HI, started crying when discussing work stress, poor eye contact, constricted affect."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Initial Evaluation for Major Depressive Disorder

Patient: 34-year-old female
Chief Complaint: "I can't stop feeling sad and I have no energy"
Visit: New patient psychiatric evaluation

S – Subjective:

Patient presents for initial psychiatric evaluation reporting persistent depressed mood for approximately 4 months. States "I feel sad almost every day and can't seem to shake it." Reports loss of interest in activities she previously enjoyed including reading, cooking, and spending time with friends. Sleep pattern disrupted with initial insomnia (takes 1-2 hours to fall asleep) and early morning awakening at 4-5am, unable to return to sleep. Total sleep approximately 4-5 hours per night. Appetite decreased with unintentional 12-pound weight loss over past 3 months. Energy level "constantly exhausted" even with minimal activity. Concentration markedly impaired, difficulty completing work tasks that were previously routine. Reports significant feelings of worthlessness and guilt, stating "I feel like I'm failing at everything." Denies current suicidal ideation but endorses passive death wishes, stating "sometimes I wish I wouldn't wake up, but I would never do anything to hurt myself." Denies homicidal ideation. No prior suicide attempts. Reports decreased libido. Symptoms began gradually following job promotion 5 months ago, initially attributed to work stress but has progressively worsened. Significant impact on functioning: calling in sick to work 2-3 times per month, withdrawn from social activities, difficulty maintaining household responsibilities. Previous mental health treatment: brief counseling in college for anxiety, no prior psychiatric medications. Family history significant for depression in mother and maternal aunt. Denies substance use except occasional wine (1-2 glasses per month). No current medications. Allergies: none known.

O – Objective:

Vital Signs: BP 118/76, HR 72, Weight 128 lbs (states usual weight 140 lbs)
Appearance: Casually dressed, appropriate for season, fair hygiene, minimal makeup
Behavior: Cooperative, makes minimal eye contact, psychomotor activity slightly slowed
Speech: Soft tone, decreased rate and volume, normal articulation
Mood: "Sad and empty" (patient's words)
Affect: Constricted, congruent with depressed mood, became tearful when discussing work difficulties
Thought Process: Linear and goal-directed, no tangentiality or circumstantiality
Thought Content: No delusions, no obsessions. Denies current suicidal ideation with plan or intent. Endorses passive death wishes without specific plan. Denies homicidal ideation. No auditory or visual hallucinations.
Cognition: Alert and oriented x3, attention and concentration impaired (unable to complete serial 7s), recent memory intact, remote memory intact
Insight: Good—recognizes symptoms are problematic and require treatment
Judgment: Fair—seeking appropriate care
PHQ-9 Score: 18 (moderately severe depression)
GAD-7 Score: 8 (mild anxiety)
Columbia Suicide Severity Rating Scale: Passive ideation without plan or intent, low acute risk

A – Assessment:

34-year-old female presenting with first episode of Major Depressive Disorder, moderate to severe, without psychotic features. Symptom duration 4 months with significant functional impairment in occupational and social domains. Meets DSM-5 criteria with depressed mood, anhedonia, sleep disturbance, appetite/weight changes, fatigue, worthlessness, impaired concentration, and passive suicidal ideation. PHQ-9 score of 18 indicates moderately severe depression. Current suicide risk assessed as low given absence of plan, intent, or means, though passive ideation present requiring monitoring. Mild comorbid anxiety symptoms. No evidence of bipolar disorder, psychotic features, or substance-induced mood disorder. Precipitating stressor appears to be occupational stress though symptoms have exceeded expected adjustment reaction. Strong family history of depression suggests genetic vulnerability. Patient has good insight and is motivated for treatment.

P – Plan:

Pharmacotherapy: Initiated sertraline 50mg PO daily, taken in morning with food. Reviewed common side effects including GI upset, initial activation, sexual side effects. Explained 2-4 week timeline for therapeutic effect. Provided education on importance of medication adherence and not discontinuing abruptly.

Psychotherapy: Provided referral to cognitive behavioral therapy (CBT) with licensed therapist in network. Discussed evidence base for combined medication and therapy approach. Patient agreeable and motivated to engage in therapy.

Safety Planning: Developed safety plan with patient. Identified warning signs of worsening depression. Created list of coping strategies including reaching out to sister (identified support), using crisis hotline (988), and contacting this office. Removed immediate access to means (no firearms in home, medications stored by partner). Patient contracted for safety, agreed to present to ED if experiences active suicidal ideation with plan or intent.

Patient Education: Discussed depression as medical condition with biological basis, not character weakness. Reviewed sleep hygiene recommendations. Encouraged gradual return to previously enjoyable activities using behavioral activation approach. Discussed importance of regular sleep schedule, physical activity, and social connection.

Monitoring: Follow-up in 2 weeks to assess medication tolerability, side effects, and early response. Instructed patient to call office immediately if experiences worsening depression, emergence of suicidal ideation with plan, or intolerable medication side effects. Provided after-hours crisis number.

Labs: Ordered TSH, CBC, CMP to rule out medical causes of depression (thyroid disease, anemia, electrolyte abnormalities).

Patient verbalized understanding of diagnosis, treatment plan, and safety precautions. Demonstrated good engagement and appropriate affect by end of session. Prognosis guarded but fair given absence of prior treatment failures and patient motivation.

---

Example 2: Follow-Up Visit, Partial Response to Treatment

Patient: 34-year-old female (same patient, 6 weeks later)
Chief Complaint: "I'm feeling somewhat better but still not myself"
Visit: Medication management follow-up

S – Subjective:

Patient returns for follow-up 6 weeks after initiating sertraline 50mg daily. Reports partial improvement in depressive symptoms. Mood "less heavy" with fewer episodes of crying. Sleep improved to 6-7 hours per night, still with some initial insomnia but less severe. Appetite returning, gained 4 pounds. Energy level improved from baseline but "still not where it should be." Anhedonia persistent, states "I can do things but don't really enjoy them yet." Concentration improved, able to complete work tasks more efficiently. Still experiencing feelings of inadequacy at work but less intense. Denies suicidal ideation, passive or active. Homicidal ideation denied. No longer experiencing passive death wishes. Has attended 4 CBT sessions, finds therapy "helpful, making me think about things differently." Medication side effects: initial nausea for first week (resolved), mild sexual dysfunction (decreased libido persists). Compliance with medication good, taking daily as prescribed. Functional status: has not missed work in past month, attended one social gathering with friends (first time in months), keeping up with household tasks.

O – Objective:

Vital Signs: BP 116/74, HR 68, Weight 132 lbs (up 4 lbs from baseline)
Appearance: Neat, appropriate grooming, wearing colorful clothing (contrast to previous visit)
Behavior: Cooperative, improved eye contact, normal psychomotor activity
Speech: Normal rate, tone, and volume
Mood: "Getting better but not all the way there" (patient's words)
Affect: Broader range than previous visit, appropriate to content, smiled appropriately during session
Thought Process: Linear, goal-directed, no abnormalities
Thought Content: No suicidal or homicidal ideation, no delusions or obsessions
Perceptions: No hallucinations
Cognition: Alert and oriented x3, concentration improved, memory intact
Insight: Excellent—recognizes improvement and identifies remaining symptoms
Judgment: Good
PHQ-9 Score: 11 (moderate depression, improved from 18)
GAD-7 Score: 6 (mild anxiety, improved from 8)

A – Assessment:

34-year-old female with Major Depressive Disorder, moderate severity, demonstrating partial response to sertraline 50mg after 6 weeks of treatment. PHQ-9 improvement from 18 to 11 indicates clinically significant response (39% reduction in score) but has not yet achieved remission (PHQ-9 less than 5). Residual symptoms include anhedonia, fatigue, and persistent feelings of inadequacy. Patient safety has improved with resolution of passive suicidal ideation. Functional status significantly improved in occupational and social domains. Tolerating medication well aside from mild sexual side effects. Engaging appropriately in therapy with reported benefit. Given partial response, dose optimization indicated per treatment algorithms.

P – Plan:

Medication Adjustment: Increased sertraline to 100mg PO daily to target residual symptoms and achieve remission. Reviewed that dose escalation is standard practice with partial response and that most patients require higher doses for full therapeutic effect. Discussed continued monitoring for side effects.

Psychotherapy: Patient to continue CBT weekly. Encouraged discussion of sexual side effects with therapist as well as ongoing work on cognitive distortions related to work performance.

Monitoring: Follow-up in 4 weeks to assess response to increased dose. Patient to contact office sooner if experiences side effect increase, mood worsening, or return of suicidal ideation.

Lifestyle: Encouraged continued behavioral activation, regular exercise, and sleep hygiene practices. Acknowledged patient's progress in returning to social activities.

Patient expressed satisfaction with progress and understanding of plan to optimize medication dosing. Agreeable to dose increase. Safety assessed as stable with no current concerns.

---

Example 3: Established Patient with Treatment-Resistant Depression

Patient: 52-year-old male
Chief Complaint: "Nothing seems to be working"
Visit: Medication management, consideration of treatment change

S – Subjective:

Patient with long-standing Major Depressive Disorder, recurrent, presents for follow-up after 8-week trial of venlafaxine XR 225mg daily (third antidepressant trial). Reports minimal improvement in depressive symptoms. Mood remains persistently low, states "I wake up every day feeling the same—empty and hopeless." Anhedonia marked, no longer participating in fishing or woodworking hobbies. Sleep severely disrupted, averaging 4-5 hours nightly with middle-of-the-night awakening. Appetite poor, weight stable. Fatigue severe, "everything feels like it takes enormous effort." Reports feelings of hopelessness but denies active suicidal ideation, states "I've promised my kids I won't do anything." No homicidal ideation. Previous medication trials: escitalopram 20mg (inadequate response after 10 weeks), bupropion XL 300mg (no response, discontinued after 8 weeks), currently on venlafaxine XR 225mg x 8 weeks (minimal response). Attends therapy every 2 weeks but reports "just going through the motions." Past psychiatric history: first episode of depression age 28, multiple recurrent episodes, two psychiatric hospitalizations (ages 35 and 46) for suicidal ideation, no suicide attempts. Currently on disability from work as construction foreman due to depression. Lives with adult daughter who provides support. Denies alcohol or illicit substance use.

O – Objective:

Vital Signs: BP 128/82, HR 76, Weight 182 lbs (unchanged)
Appearance: Disheveled, poor hygiene, unshaven, looks older than stated age
Behavior: Minimal spontaneous movement, limited engagement, poor eye contact throughout session
Speech: Soft, slow rate, increased latency to respond
Mood: "Hopeless" (patient's words)
Affect: Flat, minimal reactivity throughout interview, no smiling
Thought Process: Slowed but linear, goal-directed
Thought Content: Prominent hopelessness, denies current suicidal ideation but states "life doesn't feel worth living." No plan or intent. Denies homicidal ideation. No delusions.
Perceptions: No hallucinations
Cognition: Alert, oriented x3, attention and concentration markedly impaired, memory appears intact but difficult to assess due to poor engagement
Insight: Fair—recognizes depression but skeptical about treatment effectiveness
Judgment: Fair—continues to engage in care
PHQ-9 Score: 22 (severe depression)
Current medications: Venlafaxine XR 225mg daily, trazodone 100mg qhs for sleep

A – Assessment:

52-year-old male with Major Depressive Disorder, recurrent, severe, demonstrating treatment resistance. Has failed adequate trials of SSRI (escitalopram), NDRI (bupropion), and SNRI (venlafaxine) at therapeutic doses and durations. PHQ-9 of 22 indicates severe depression without improvement from previous scores. Significant functional impairment with disability from work. Chronic passive suicidal ideation without current acute risk, though requires close monitoring given history of two psychiatric hospitalizations. Patient meets criteria for treatment-resistant depression (failure to respond to at least two antidepressants from different classes at adequate doses and durations). Consideration of augmentation strategies or alternative treatments warranted. Patient engagement in psychotherapy suboptimal, may reflect severity of depression.

P – Plan:

Treatment Modification: Discussed treatment-resistant depression and available options including: (1) augmentation with atypical antipsychotic (aripiprazole or quetiapine), (2) switching to different medication class (MAOIs, tricyclics), (3) electroconvulsive therapy (ECT), (4) transcranial magnetic stimulation (TMS), (5) ketamine/esketamine therapy. Given severity and functional impairment, recommended consultation with psychiatrist specializing in treatment-resistant depression for comprehensive evaluation and potential ECT or TMS candidacy. Patient somewhat interested in exploring these options though expressing skepticism.

Current Medication Management: Continue venlafaxine XR 225mg and trazodone 100mg while pursuing specialty consultation. Discussed that abrupt discontinuation could worsen symptoms.

Safety: Given severity and passive suicidal ideation, reviewed safety plan. Patient's daughter present in session, will monitor closely. Patient continues to deny intent or plan, maintains protective factors (responsibility to children). Agreed to contact emergency services or present to ED if active suicidal ideation emerges. Provided daughter with warning signs to monitor.

Coordination of Care: Will send referral to Dr. Johnson at Regional Psychiatric Center for treatment-resistant depression evaluation. Expedited appointment requested given severity. Will also reach out to patient's therapist to discuss increasing session frequency and reviewing treatment approach.

Follow-up: Appointment in 1 week for safety check and to ensure specialty referral is progressing. Patient to call immediately if safety concerns arise.

Patient demonstrated understanding of plan though continues to express hopelessness about treatment outcomes. Emphasized that treatment-resistant depression has multiple evidence-based options he has not yet tried. Daughter voiced support and commitment to monitoring.

---

Key Components Insurance Companies Look For in Depression SOAP Notes

When reviewing your depression documentation, insurance companies specifically want to see:

1. Validated Symptom Severity Measures

Use PHQ-9, GAD-7, or other standardized tools. Document scores at each visit to show symptom tracking and treatment response.

2. Functional Impairment Documentation

Clearly describe impact on work, relationships, self-care, and daily activities. This demonstrates medical necessity for treatment.

3. Safety Assessment

Every note should include suicide risk evaluation. Document ideation (passive vs. active), plan, intent, means, and protective factors.

4. Treatment History

Document previous medications tried, doses, duration, and response. This justifies current treatment choices and demonstrates appropriate escalation.

5. Mental Status Examination

Document objective findings including appearance, behavior, mood, affect, thought process, and cognition. This validates subjective complaints.

6. Treatment Rationale

Explain why specific medications or therapies are chosen. Reference guidelines or evidence-based practices when possible.

7. Response to Treatment

Compare current symptoms and functioning to previous visits. Document improvement, stability, or worsening with specific examples.

Common Mistakes to Avoid

Vague Symptom Documentation: Instead of "patient is depressed," document specific symptoms: "reports anhedonia, early morning awakening at 4am, 15-pound weight loss, difficulty concentrating at work."

Missing PHQ-9 Scores: Use validated tools at each visit. Insurance increasingly requires objective measures for continued authorization.

Inadequate Safety Assessment: Never skip suicide risk evaluation. Document what you asked and what the patient reported, not just "denies SI."

No Functional Impact: Insurance wants to see how depression affects the patient's life. Document specific examples of impairment.

Missing Treatment Justification: When changing medications or adding therapy, explain the clinical reasoning based on symptoms, side effects, or treatment resistance.

Incomplete Mental Status Exam: Document all components (appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, judgment).

No Comparison to Baseline: Show trends in PHQ-9 scores, symptom severity, and functional capacity across visits to demonstrate treatment progress or need for adjustment.

Final Thoughts

Depression SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent building therapeutic relationships and providing quality mental health care than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

---

Ready to simplify your depression documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.