As healthcare professionals, in our work, we see many patients struggling with anxiety. It is a common condition. It can be hard to treat. Good notes are our best tool. They help us track progress. They help us make good choices. The SOAP note is a key format. SOAP stands for Subjective, Objective, Assessment, and Plan. This guide will show you how to write a great SOAP note for anxiety. This is for both experienced and new clinicians. It is also for those who want a quick review. Good notes lead to good patient care.

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Anxiety is not just feeling nervous. It is a real medical condition. It affects the mind and body. Patients may have fast heart rates. They may have trouble sleeping. They may have constant worry. Our notes must capture all of this. The SOAP note helps us do that in an organized way. Each section has a purpose. Together, they tell the patient’s story. They show where the patient started. They show how the patient is doing now. They show our plan for the future.

Think of the SOAP note as a map. It guides us and other providers. If another doctor sees our patient, our note should give them a clear picture. It should show what we have tried. It should show what has worked and what has not. This is very important for conditions like anxiety. Treatment often changes over time. We adjust medications. We change therapy techniques. Our notes are the record of this journey. Let us look at each part of the map, one step at a time.

Subjective (What the Patient Tells You)

What is the “S” in SOAP?

The “S” stands for Subjective. This is the patient’s story in their own words. We cannot see or measure this part directly. We must listen to the patient. We write down what they say. We use quotes when we can. For anxiety, this section is very important. It tells us how the patient feels inside. We learn about their fears and worries. We learn what makes their anxiety better or worse.

In this section, we write the Chief Complaint (CC). This is the main reason for the visit. We also write the History of Present Illness (HPI). This gives details about the CC. We ask about medications. We ask about their social history. All of this is subjective. It comes from the patient’s point of view. Our job is to listen carefully and write it down clearly.

Key Questions to Ask for Anxiety

We need to ask the right questions. Here are some simple ones:

• “What does your anxiety feel like in your body?”
• “What thoughts go through your mind when you are anxious?”
• “When did this current worry start?”
• “What makes it worse? What makes it a little better?”
• “How is this affecting your daily life? Your work? Your family?”

We should also ask about safety. We must always ask: “Has the anxiety ever made you think about hurting yourself or others?” This is a critical question. We must document the answer every time. We also ask about their current medications. Are they taking them? Do they have side effects?

Example of a Strong “Subjective” Section

CC: “I can’t stop worrying. My heart races all the time.”

HPI: Jane Doe is a 34-year-old female here for a follow-up on Generalized Anxiety Disorder. She states, “The last two weeks have been very hard.” She reports increased worry about her job performance and her children’s health. This worry is present “more days than not.” She describes physical symptoms including muscle tension in her shoulders, restlessness (“I can’t sit still”), and difficulty falling asleep (takes 2 hours most nights). She notes that exercise “helps a little,” but deadlines at work make it “much worse.” She denies any thoughts of hurting herself or others. Current medications: Sertraline 50mg daily. She reports taking it regularly but “is not sure if it’s working yet.”

Social History: Works as an accountant. Married with two young children. Denies use of alcohol or illicit drugs. Drinks 2 cups of coffee daily.

Objective (What You See, Hear, and Measure)

What is the “O” in SOAP?

The “O” stands for Objective. This is the part we can see, hear, or measure. It is the facts. It is not the patient’s feelings. For anxiety, we look at many things. We look at how the patient acts. We measure their vital signs. We can use rating scales. This section should be clear and neutral. We just write what we observe.

Why is this important? Sometimes a patient says they feel “terrible,” but they look calm. Sometimes a patient says they are “fine,” but their hands are shaking. The objective section shows this difference. It gives us data. We can track this data over time to see if the patient is getting better.

What to Include in the Objective Section for Anxiety

First, always include Vital Signs: Blood pressure, heart rate, respiratory rate, and temperature. A high heart rate can be a sign of anxiety.

Next, write your General Observations. This is often called “Appearance.” How does the patient look? How do they act?

• Appearance: Well-dressed? Disheveled? Good eye contact?
• Behavior: Calm? Fidgeting? Pacing? Crying?
• Speech: Fast? Slow? Normal volume?Then, you can use a Rating Scale. A common one is the GAD-7 (Generalized Anxiety Disorder 7-item scale). It gives a score from 0 to 21. This score helps us measure anxiety level. We can compare the score from last visit to this visit. It is a good objective tool. Finally, note any Physical Exam findings related to anxiety. This might not be a full exam. But you can note: “Muscle tension palpable in trapezius muscles.” Or “Hands are trembling.”

Example of a Strong “Objective” Section

Vital Signs: BP 142/88, HR 112 bpm, RR 18, Temp 98.6°F.

Appearance & Behavior: Patient is alert and oriented. She is well-groomed but makes poor eye contact. She is fidgeting with her hands throughout the interview. Speech is rapid at times.

Mental Status Exam: Mood described as “anxious.” Affect is tense and restricted. Thought process is logical but racing. Denies suicidal or homicidal ideation. No psychosis noted.

Assessment Tool: GAD-7 score: 15 (indicative of severe anxiety). Score last visit 4 weeks ago was 10.

Physical Exam (Focused): Neurological exam: mild tremor in both hands. Musculoskeletal: notable tension and tenderness in shoulder and neck muscles.

Assessment (Your Professional Diagnosis and Analysis)

What is the “A” in SOAP?

The “A” stands for Assessment. This is your professional opinion. It is not just restating what the patient said. You take the Subjective and Objective information and you analyze it. You make sense of it. For anxiety, this is where you give your diagnosis. You also discuss how the patient is doing. Are they better? Worse? The same? This is the “so what?” part of the note.

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Think of yourself as a detective. The Subjective and Objective sections are your clues. The Assessment is where you say what you think the clues mean. You explain your reasoning. This is also where you can list other possible conditions (differential diagnoses) if the picture is not clear.

How to Write the Assessment for an Anxiety Disorder

Start with your main Diagnosis. Use the official code if you know it (like F41.1 for Generalized Anxiety Disorder). Then, write a few sentences that tie the S and O to the A. This shows you are thinking critically.

For example: “The patient’s reported constant worry (S), elevated heart rate and GAD-7 score of 15 (O) support the diagnosis of GAD, which appears to be worsening.”

Also, note the patient’s Progress. Are they meeting their treatment goals? Why or why not? “Patient has worsened since last visit, possibly related to increased stressors at work.

Medication adherence is good, but therapeutic effect may not be optimal at current dose.”

You can also note any Safety Concerns or Rule-Outs. “Despite worsening anxiety, patient continues to deny SI/HI, which is reassuring.”

Example of a Strong “Assessment” Section

Diagnosis:

1. F41.1 Generalized Anxiety Disorder, worsening.Analysis:Patient presents with a clear increase in subjective anxiety symptoms and objective markers (elevated HR, increased GAD-7 score from 10 to 15). This exacerbation coincides with a reported stressful period at work. She is adherent to her current medication regimen, but the Sertraline 50mg daily may be insufficient for her current symptom severity. There are no immediate safety concerns.

Plan (What You and the Patient Will Do Next)

What is the “P” in SOAP?

The “P” stands for Plan. This is the action section. Based on your Assessment, what will you do? What will the patient do? The plan must be clear and specific. Anyone reading it should know the next steps. A good plan addresses all parts of the problem. For anxiety, the plan often has several parts: medication, therapy, lifestyle, and follow-up.

The plan is a shared agreement. You should discuss it with the patient. Make sure they understand it. Write down what you both decide. A vague plan is not helpful. “Increase medication” is vague. “Increase Sertraline to 75mg daily” is specific and clear.

Creating a Comprehensive Plan for Anxiety

A strong plan has several parts:

1. Medications: List any changes, starts, or stops. Include the dose, how often to take it, and for how long. Explain why.
2. Therapies: Refer to or continue psychotherapy (like CBT). Give “homework” (e.g., “Practice deep breathing for 5 minutes twice daily”).
3. Lifestyle/Education: Discuss sleep hygiene, cutting down caffeine, exercise plans, or stress management tools.
4. Safety Plan: If needed, document a specific safety plan. “Patient will call 988 if SI emerges.”
5. Follow-up: When will you see them next? “Follow up in 2 weeks to assess response to medication increase.”
6. Tests/Referrals: Usually not needed for routine anxiety, but could include “Refer to psychiatrist for medication management” if needed.

Example of a Strong “Plan” Section

Plan:

1. Medication: Increase Sertraline from 50mg to 75mg daily to better control worsening symptoms. Patient instructed on new dose. Discussed potential side effects (nausea, insomnia) and advised to take with food.
2. Therapy: Strongly encouraged to resume CBT sessions with therapist, which she paused 1 month ago. Provided with a list of in-network therapists. For skills practice, patient agreed to use a guided meditation app for 10 minutes before bed.
3. Lifestyle & Education: Advised to reduce caffeine intake from 2 cups to 1 cup of coffee in the morning only. Discussed importance of sleep routine. Patient will try a warm shower and reading (not screens) before bed.
4. Safety: Patient continues to deny SI/HI. Instructed to call clinic or go to ER if she develops any thoughts of self-harm.
5. Follow-up: Schedule follow-up appointment in 2 weeks to re-evaluate symptoms and medication tolerance. Will repeat GAD-7 at that visit.
6. Referrals: None at this time.

Putting It All Together: A Full Example of Anxiety SOAP Note

Conclusion: Better Notes, Better Care

Writing a good SOAP note for anxiety takes practice. But it is worth the effort. It helps us think clearly about our patients. It creates a strong record for the future. It helps the whole team provide good care. Remember the four parts: Subjective (their story), Objective (our facts), Assessment (our opinion), and Plan (our actions). Use simple words. Be specific. Your notes will be powerful tools. They will help you guide your patients from anxiety toward calm and health. Thank you for the important work you do.

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