Sample Soap Note

S: Pt was willing to participate in therapy today and brought her notebook. Pt reports using coping strategy (worry time) 100% of trials. Sleep programming worksheet revealed an overall sleep efficiency rating of 85% for the past week. Pt was able to exercise before work for 30 min. on 5/5 trials without complaint.

O and A: Pt tolerated therapy well. Worked with pt on updating sleep programming worksheet, adding 1 additional behavioral strategy (using mindfulness after writing down to dos and worries). Completed cog. restructuring exercise (facts for/against table) with mod verbal cueing to use as coping strategy when overwhelmed. Made plan to socialize at least 1x with a peer or group of peers over the next week. Role played reciprocity for upcoming difficult social situation (work meeting) with min verbal cueing.

P: Thoughtful questions worksheet

Billing: 4 units of 97535 for the 60 min. session