Complete Guide to Postpartum Depression SOAP Note Examples for Healthcare Providers

If you've ever struggled to document postpartum mental health visits in a way that meets insurance requirements while addressing the unique challenges of new mothers, this guide is for you.

I've talked to countless OBGYNs, family physicians, psychiatrists, and nurse practitioners who see new mothers struggling with postpartum depression but find the documentation process overwhelming.

The reality is that postpartum depression documentation has specific requirements that go beyond standard depression notes.

Insurance companies want to see clear assessment of maternal-infant bonding, safety evaluation for both mother and baby, screening with validated tools, and evidence that treatment won't harm breastfeeding infants.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on supporting new mothers through this vulnerable period.

In this article, I'll show you exactly how to write postpartum 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 Postpartum Depression)

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

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

• Clear documentation of symptom onset relative to delivery
• Appropriate screening using validated instruments (EPDS, PHQ-9)
• Assessment of maternal-infant bonding and infant safety
• Safety evaluation including infanticide risk and suicide risk
• Consideration of breastfeeding status in treatment planning
• Evidence of treatment response and functional improvement

SOAP stands for:

• S — Subjective: What the mother reports about mood, anxiety, bonding with baby, intrusive thoughts, sleep (beyond infant care), appetite, and feelings about motherhood.
• O — Objective: Your clinical findings including mental status exam, appearance, affect, EPDS score, and observations of mother-infant interaction if applicable.
• A — Assessment: Your clinical diagnosis with onset timing, severity assessment, risk stratification, and evaluation of bonding and safety concerns.
• P — Plan: Your treatment plan including medication management (with breastfeeding considerations), therapy referrals, support resources, safety planning, and infant welfare assessment.

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 while documenting critical safety considerations unique to postpartum patients.

How You Can Approach Postpartum Depression SOAP Notes

There's no single correct method for writing postpartum 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 all the unique elements of postpartum mental health—bonding assessment, breastfeeding considerations, infant safety—can be overwhelming when you're managing a full schedule.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, 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 postpartum mental health documentation.

How to Make Postpartum Depression SOAP Notes Faster

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

You've just finished a full day of appointments, each requiring careful assessment of both maternal mental health and infant safety, and instead of catching up on messages or going home to rest, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk missing critical safety documentation; 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?

"EPDS 16, patient tearful throughout visit, reports difficulty bonding with infant, intrusive thoughts of baby being harmed but no intent, exclusively breastfeeding, partner supportive, denies SI but endorses hopelessness."

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

Example 1: Screening Positive at 6-Week Postpartum Visit

Patient: 28-year-old G2P2 female
Delivery: 6 weeks ago, uncomplicated vaginal delivery
Chief Complaint: Routine postpartum visit, screening positive for depression
Visit: 6-week postpartum check

S – Subjective:

Patient presents for routine 6-week postpartum examination. During routine screening, scored 16 on Edinburgh Postnatal Depression Scale (EPDS), prompting further evaluation. Reports feeling overwhelmed and tearful "most of the time" for past 3 weeks. States "I thought I'd be happier with a new baby, but I just feel exhausted and sad." Describes crying episodes multiple times daily, often without clear trigger. Reports significant anxiety about infant care, constantly worrying "I'm doing everything wrong." Sleep severely disrupted beyond expected newborn care—even when baby sleeps, patient lies awake worrying or feeling unable to sleep. When baby sleeps and patient has opportunity to rest, reports "my mind races and I can't turn it off." Appetite decreased, eating irregularly, has lost 8 pounds beyond expected postpartum weight loss. Reports difficulty bonding with infant initially but states "I love my baby and want to take good care of him." Denies thoughts of harming infant or self but reports intrusive thoughts of baby being injured (dropping baby, baby stopping breathing) that cause significant distress. Recognizes thoughts are unwanted and ego-dystonic. Describes feeling guilty for "not being a good enough mother" and comparing self unfavorably to other mothers on social media. Partner supportive but works long hours. Family support limited, mother lives out of state. First child (age 3) requires attention, causing patient to feel "torn between two kids and failing both." No prior history of depression or anxiety. Breastfeeding exclusively with adequate milk supply but reports feeling "trapped" by feeding schedule. Denies alcohol or substance use. No current medications aside from prenatal vitamin.

O – Objective:

Vital Signs: BP 118/74, HR 82, Weight 138 lbs (pre-pregnancy 135 lbs, delivery weight 168 lbs, down 30 lbs from delivery)
General: Appears fatigued, tearful during interview, makes intermittent eye contact
Grooming: Hair pulled back, minimal makeup, clothing clean but casual
Behavior: Cooperative, psychomotor activity normal, became tearful multiple times when discussing feelings about motherhood
Speech: Normal rate and tone, coherent
Mood: "Overwhelmed and sad" (patient's words)
Affect: Anxious and tearful, congruent with mood, range somewhat constricted
Thought Process: Linear, goal-directed, some rumination about perceived parenting failures
Thought Content: Intrusive thoughts of infant being harmed (ego-dystonic, no intent to harm), denies suicidal ideation, denies homicidal ideation, denies thoughts of infanticide, no delusions
Perceptions: No hallucinations, no dissociative symptoms
Cognition: Alert, oriented x3, attention fair (some difficulty concentrating due to anxiety), memory intact
Insight: Good—recognizes symptoms are concerning and seeks help
Judgment: Good—engaging in appropriate care
Mother-Infant Interaction: Not directly observed during visit but patient describes feeding baby, changing diapers, responding to cries appropriately
EPDS Score: 16 (scores ≥13 indicate likely depression, question 10 regarding self-harm scored 0)
GAD-7 Score: 12 (moderate anxiety)
Physical Exam: Postpartum healing normal, no complications noted

A – Assessment:

28-year-old woman 6 weeks postpartum presenting with postpartum depression, moderate severity, with comorbid anxiety. Symptom onset approximately 3 weeks postpartum with progressive worsening. EPDS score of 16 indicates clinically significant postpartum depression. Patient meets DSM-5 criteria for Major Depressive Disorder with peripartum onset: depressed mood, anhedonia, sleep disturbance (beyond infant care), appetite changes, fatigue, feelings of worthlessness, impaired concentration. Comorbid anxiety symptoms prominent with GAD-7 of 12. Intrusive thoughts regarding infant harm are ego-dystonic and consistent with postpartum anxiety/OCD features rather than psychosis or intent to harm. No current suicide risk—denies ideation, plan, or intent. No infanticide risk—patient protective of infant, thoughts are unwanted and distressing rather than desired. Bonding concerns present but patient demonstrates appropriate attachment and protective instincts. Risk factors include limited social support, demands of caring for two young children, disrupted sleep, and first episode of mood disorder. Currently breastfeeding, which requires consideration in treatment planning. No evidence of postpartum psychosis.

P – Plan:

Psychopharmacology: Discussed medication options compatible with breastfeeding. Initiated sertraline 25mg PO daily (will increase to 50mg after one week), safest SSRI for breastfeeding per current evidence with minimal infant exposure. Reviewed that benefits of treating maternal depression outweigh minimal risks to infant through breast milk. Patient agreeable to medication trial. Reviewed common side effects and timeline for therapeutic response (2-4 weeks).

Psychotherapy: Provided referral for therapy specializing in perinatal mental health. Discussed evidence base for cognitive-behavioral therapy and interpersonal therapy for postpartum depression. Patient motivated to engage in therapy. Discussed that therapy can address intrusive thoughts, bonding concerns, and adjustment to motherhood.

Safety Assessment and Planning: Assessed safety of mother and infant. Patient denies suicidal ideation and intent to harm infant. Intrusive thoughts are ego-dystonic (unwanted, causing distress) rather than psychotic or reflecting intent. No delusional thinking about infant. Developed safety plan including: contact crisis line (988) if thoughts change, reach out to partner or friend for support, contact this office if symptoms worsen. Emphasized importance of accepting help with childcare to allow for rest.

Support and Resources: Provided information on local postpartum support groups (both in-person and virtual options). Discussed importance of accepting help from partner, friends, or family with childcare and household tasks. Encouraged patient to limit social media use which triggers comparisons and guilt. Discussed sleep hygiene and recommended sleeping when baby sleeps rather than using that time for chores.

Breastfeeding: Supported continued breastfeeding if desired but normalized that some mothers choose to stop or supplement with formula to reduce feeling of being "trapped." Emphasized that fed is best and mother's mental health is critical to infant wellbeing. Patient wishes to continue breastfeeding currently.

Monitoring: Close follow-up in 2 weeks to assess medication response, side effects, and safety. Instructed patient to call immediately if experiences worsening depression, suicidal thoughts, or thoughts of harming infant. Provided after-hours crisis number. Will reassess EPDS at next visit to track treatment response.

Coordination: Will communicate with pediatrician regarding maternal mental health (with patient consent) to ensure infant wellness checks include inquiry about maternal wellbeing.

Patient verbalized understanding of diagnosis, treatment plan, and when to seek immediate help. Partner present for portion of visit, educated on warning signs and ways to support patient. Prognosis good with appropriate treatment and support.

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Example 2: Established Patient, 6 Weeks Into Treatment

Patient: 28-year-old female (same patient as Example 1)
Postpartum: 12 weeks
Chief Complaint: "I'm feeling better but still having hard days"
Visit: Postpartum depression treatment follow-up

S – Subjective:

Patient returns for follow-up 6 weeks after initiating treatment for postpartum depression. Currently taking sertraline 50mg daily for past 5 weeks (was increased from 25mg after first week). Reports significant improvement in mood and anxiety. Crying episodes decreased from multiple times daily to "maybe once or twice a week when I'm really tired." States "I feel more like myself again." Sleep improved—able to fall asleep when baby sleeps, though still waking for nighttime feedings. Appetite normalized, eating three meals daily. Intrusive thoughts about infant harm have decreased markedly in frequency and intensity, now occurs "maybe once every few days and doesn't bother me as much." Bonding with infant has improved significantly, reports "I feel more connected to him now, I enjoy our time together." Still experiences some anxiety about parenting but manageable and not interfering with function. Guilt about "not being perfect" persists but less intense. Has attended 4 therapy sessions, finds it "very helpful, learning tools to challenge my negative thoughts." Continues breastfeeding, now views it more positively. Partner has been more involved with nighttime care to help patient get longer sleep stretches. Patient's mother visited for one week which provided additional support. Denies suicidal ideation or thoughts of harming infant. No medication side effects reported. Taking medication daily as prescribed.

O – Objective:

Vital Signs: BP 114/70, HR 74, Weight 140 lbs
Appearance: Well-groomed, appropriate dress, bright affect
Behavior: Engaged, good eye contact, smiling appropriately
Speech: Normal rate, tone, and volume
Mood: "Much better, more hopeful" (patient's words)
Affect: Euthymic, appropriate range, reactive
Thought Process: Linear, goal-directed, no rumination observed
Thought Content: Rare intrusive thoughts (decreased frequency and intensity), no suicidal ideation, no thoughts of harming infant, no delusions
Perceptions: No hallucinations
Cognition: Alert, oriented x3, concentration improved, memory intact
Insight: Excellent—recognizes improvement and identifies remaining challenges
Judgment: Good
EPDS Score: 8 (improved from 16, scores less than 10 suggest recovery)
GAD-7 Score: 6 (mild anxiety, improved from 12)

A – Assessment:

28-year-old woman 12 weeks postpartum with postpartum depression, now in partial remission with combined medication and psychotherapy. EPDS improvement from 16 to 8 represents clinically significant response (50% reduction). Residual symptoms include intermittent anxiety and mild intrusive thoughts, but significantly decreased from baseline. Maternal-infant bonding has improved with patient reporting enjoyment of caregiving and emotional connection. Functional capacity restored with ability to care for both children and manage household. Safety concerns resolved—no suicidal ideation and intrusive thoughts now manageable. Tolerating sertraline 50mg well without side effects. Actively engaged in therapy with reported benefit. Prognosis excellent with continued treatment.

P – Plan:

Medication Management: Continue sertraline 50mg daily. Current dose providing good response with minimal residual symptoms. Will reassess need for dose adjustment at next visit if symptoms plateau or worsen. Emphasized importance of continuing medication for at least 6-12 months to prevent relapse, even with symptom improvement.

Psychotherapy: Continue weekly therapy sessions. Patient finding CBT techniques helpful for managing residual anxiety and intrusive thoughts. Encouraged continued work on self-compassion and realistic expectations of motherhood.

Monitoring: Follow-up in 6 weeks unless concerns arise. Will continue tracking EPDS scores to ensure sustained improvement and early detection of any relapse.

Support: Encouraged continued acceptance of help from partner and family. Discussed maintaining self-care activities including sleep, nutrition, and brief periods of time for self.

Breastfeeding: Supportive of patient's decision to continue breastfeeding. Reassured that sertraline continues to be safe with minimal infant exposure.

Future Planning: Discussed that postpartum depression increases risk for recurrence in future pregnancies. If patient plans future children, will benefit from early screening and possible prophylactic treatment.

Patient expressed satisfaction with progress and understanding of continued treatment plan. Demonstrating excellent insight and engagement in recovery. Will continue monitoring for sustained improvement.

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Example 3: Severe Postpartum Depression with Psychotic Features

Patient: 32-year-old G1P1 female
Postpartum: 3 weeks
Chief Complaint: Emergency visit - "My partner says I'm not acting right"
Visit: Urgent psychiatric evaluation

S – Subjective:

Patient brought in by partner for emergency evaluation due to concerning behavior over past week. Partner reports patient has become increasingly withdrawn, not sleeping even when infant sleeps, expressing bizarre beliefs about infant being "possessed" or "not really mine." Patient initially reluctant to engage but with gentle redirection provides limited history. Reports feeling "disconnected from reality" and hearing voice (singular) telling her "the baby is in danger and needs to be sent back." States she doesn't sleep because she must "watch the baby constantly to protect it from evil." Denies the voice tells her to harm infant but states "I know the baby isn't safe here." Reports no appetite, losing weight rapidly. Describes feeling "numb" toward infant, states "I don't feel like this baby's mother." Denies breastfeeding—milk dried up several days ago. Partner reports patient had been tearful and anxious in first week postpartum but symptoms escalated dramatically over past 7 days with onset of delusional thinking. Delivery was complicated by emergency cesarean section for fetal distress after 18 hours of labor. Partner reports patient has not been sleeping more than 2-3 hours per 24-hour period for past 5 days. Family history notable for bipolar disorder in patient's aunt. Patient denies personal psychiatric history though partner reports patient had "mood swings" during pregnancy that were attributed to hormones. When asked about thoughts of harming self or infant, patient states "I would never hurt the baby, I need to protect the baby," but partner reports patient made comment yesterday about "maybe the baby would be better off without me."

O – Objective:

Vital Signs: BP 138/88, HR 96, Temperature 98.6°F, Weight 152 lbs (partner states pre-pregnancy weight was 145 lbs, delivery weight was 178 lbs)
Appearance: Disheveled, poor hygiene, unwashed hair, wearing same clothes as yesterday per partner, appears exhausted
Behavior: Guarded, limited eye contact, psychomotor agitation, wringing hands, scanning room frequently
Speech: Soft, slow, at times difficult to hear
Mood: "Confused" (patient's word)
Affect: Flat with brief periods of intense anxiety, incongruent at times
Thought Process: Tangential at times, circumstantial, difficult to redirect
Thought Content: Delusional belief that infant is "possessed" or "not really hers," paranoid ideation that infant is in danger from vague external threat, unclear suicidal ideation ("maybe baby better off without me"), denies infanticide intent but concerning given delusions about infant
Perceptions: Auditory hallucination (single voice commenting on infant's danger), denies visual hallucinations
Cognition: Alert, oriented to person and place but not fully oriented to time (states date incorrectly by 4 days), attention severely impaired, concentration poor, insight severely impaired
Judgment: Severely impaired—unable to recognize symptoms as illness
Mother-Infant Interaction: Infant brought to visit—patient sits apart from infant, makes no move to comfort when infant cries, appears detached and fearful of infant

A – Assessment:

32-year-old woman 3 weeks postpartum presenting with postpartum psychosis, severe. Acute onset of psychotic symptoms including auditory hallucinations and delusions with themes of infant harm/danger and depersonalization from infant. Meets criteria for Brief Psychotic Disorder with postpartum onset. High-risk presentation given: (1) auditory hallucinations with content about infant danger, (2) delusional beliefs about infant, (3) severe sleep deprivation, (4) impaired reality testing, (5) detachment from infant, (6) possible suicidal ideation, (7) family history of bipolar disorder. Risk of infanticide and suicide is significantly elevated in postpartum psychosis. Patient requires immediate psychiatric hospitalization for stabilization and safety. Infant safety is of immediate concern—mother currently unable to safely care for infant. Possible underlying bipolar disorder given family history and rapid onset of psychotic symptoms. Complicated delivery and sleep deprivation are precipitating factors.

P – Plan:

Immediate Hospitalization: Patient requires immediate inpatient psychiatric admission for safety of both mother and infant. Explained to patient and partner that symptoms represent serious psychiatric emergency requiring hospital-level care. Contacted inpatient psychiatric unit, bed available, patient will be admitted today via emergency evaluation. Partner agrees with hospitalization plan and will provide transportation.

Infant Safety: Discussed with partner that patient cannot safely care for infant at this time. Partner will assume full infant care responsibilities. Verified partner has adequate support (maternal grandmother will stay with family). Recommended pediatrician be notified of situation for infant wellness monitoring. No evidence of infant harm or neglect to date.

Medication Management: Recommendations for inpatient team include: (1) antipsychotic medication (risperidone or olanzapine) for psychotic symptoms, (2) potential mood stabilizer given family history of bipolar disorder, (3) sleep restoration as priority. Explained to patient and partner that medication will not harm her and is necessary for recovery.

Safety Planning: Given risk of suicide and infanticide, patient requires constant supervision until hospitalized. Partner instructed not to leave patient alone with infant. Partner instructed to proceed directly to psychiatric emergency department. Provided crisis hotline number (988) and instructed to call 911 if safety concerns escalate during transport.

Breastfeeding: Patient not currently breastfeeding (milk supply ceased). Discussed with partner that medications needed for treatment would contraindicate breastfeeding regardless. Emphasized that mother's mental health takes absolute priority.

Coordination of Care: Will communicate with inpatient psychiatric team regarding presentation and diagnostic impressions. Requested updates on patient progress and discharge planning. Offered to provide outpatient follow-up upon discharge.

Education: Provided psychoeducation to partner about postpartum psychosis, emphasizing this is medical emergency, not patient's fault, and highly treatable with appropriate intervention. Discussed typical hospital stay of 1-2 weeks with good prognosis for recovery with treatment.

Follow-up: Patient will be followed by inpatient team. Will see patient for outpatient follow-up within one week of hospital discharge for medication management and continued monitoring. Partner to update this office on hospital course.

Partner verbalized understanding of seriousness of situation and plan for immediate hospitalization. Patient has limited insight but agreed to "go to hospital to rest." Prognosis good with appropriate treatment though close monitoring will be needed long-term given possible bipolar diagnosis.

Documentation Note: Notified attending physician and documented emergency presentation per institutional protocol. CPS notification not indicated at this time given no evidence of neglect, infant is safe with competent caregiver, and patient is accepting appropriate level of care.

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Key Components Insurance Companies Look For in Postpartum Depression SOAP Notes

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

1. Edinburgh Postnatal Depression Scale (EPDS) Scores

Use EPDS at screening and follow-up visits. Document scores and track changes over time to demonstrate treatment necessity and response.

2. Timing Relative to Delivery

Clearly document onset of symptoms in relation to delivery (e.g., "3 weeks postpartum"). Peripartum onset has specific diagnostic and treatment implications.

3. Maternal-Infant Bonding Assessment

Document attachment quality, ability to care for infant, and any concerns about bonding. This justifies treatment urgency and demonstrates functional impact.

4. Safety Evaluation for Mother AND Infant

Every note must assess suicide risk AND risk to infant (infanticide risk, intrusive thoughts, ability to safely care for infant). Document protective factors and safety planning.

5. Breastfeeding Status and Treatment Considerations

Document whether patient is breastfeeding and how this impacts medication selection. Show you've considered infant safety in treatment planning.

6. Differentiation from "Baby Blues"

Document symptom duration and severity to distinguish postpartum depression (symptoms greater than 2 weeks, significant impairment) from normal postpartum adjustment.

7. Screening for Postpartum Psychosis

Document absence of psychotic symptoms (or presence if applicable). Postpartum psychosis is medical emergency requiring different treatment approach.

Common Mistakes to Avoid

Missing EPDS Screening: Use validated screening tools at routine postpartum visits. "Patient seems fine" is inadequate documentation.

Inadequate Safety Documentation: Never skip assessment of both maternal suicide risk AND thoughts about harming infant. Document specific questions asked and responses.

Not Distinguishing Baby Blues from PPD: Document symptom duration (baby blues resolve by 2 weeks postpartum), severity, and functional impairment to justify diagnosis.

Ignoring Breastfeeding in Treatment Planning: Always document breastfeeding status and medication compatibility. This shows appropriate treatment selection.

Missing Bonding Assessment: Document quality of maternal-infant attachment, not just absence of harm. Bonding difficulties warrant intervention even without safety concerns.

Vague Symptom Documentation: Instead of "patient is depressed postpartum," document: "patient reports anhedonia when caring for infant, difficulty bonding, guilt about not feeling joy, crying during most feedings."

No Follow-Up Timeline: Postpartum patients need close monitoring. Document specific follow-up intervals and criteria for more urgent contact.

Failing to Screen for Psychosis: Always ask about hallucinations, delusions, and disorganized thinking. Missing postpartum psychosis has catastrophic consequences.

Final Thoughts

Postpartum 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—including the unique elements of postpartum mental health—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, ensures infant safety, and satisfies insurance requirements.

Your time is better spent supporting new mothers through this vulnerable period 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.

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