SOAP Note Example: Ethics and Risk Management Anxiety

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Subjective:
Client attended a 45-minute virtual session and appeared stressed. Client reported worsening anxiety about their work as a therapist, stating, "I'm constantly terrified I'm going to mess up and hurt someone or get reported." They described obsessive behaviors such as rereading documentation repeatedly, lying awake at night replaying sessions, and worrying about saying the wrong thing or not properly assessing risk. Client acknowledged that their performance is objectively good, citing no complaints and positive feedback from their supervisor, but noted they are unable to stop the worry.

Objective:
Session was conducted virtually for 45 minutes. Client appeared stressed and discussed obsessive rumination and reassurance-seeking behaviors, including rereading notes, consulting colleagues excessively, and researching ethics questions late at night. Therapist provided psychoeducation on how these behaviors maintain anxiety rather than reduce it.

Assessment:
Client is experiencing significant anxiety and perfectionism related to their work as a therapist, which is interfering with their ability to trust their own judgment. Client demonstrated insight into the issue but appeared hesitant about implementing changes. Progress was made in identifying reassurance-seeking behaviors and developing initial strategies to address them.

Plan:
Client was assigned homework to limit documentation review to one check after writing and to start an evidence list of their competence, including feedback and successful situations. Therapist and client will meet next week to evaluate progress and continue working on building self-trust and reducing reassurance-seeking behaviors.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over, and then Quill would generate a note similar to the one above.

We had a 45-minute virtual session today. Dr. Patel logged in looking stressed and said the anxiety about their work has been getting worse. They're a therapist, and they said quote 'I'm constantly terrified I'm going to mess up and hurt someone or get reported' unquote. They described how they obsess over documentation, rereading their notes over and over to make sure they didn't miss anything. They'll lie awake at night replaying sessions, worrying they said the wrong thing or didn't assess risk properly. They said they know their performance is actually good, they've never had a complaint, their supervisor gives positive feedback, but they can't stop the worry.

We talked about how this is less about actual risk and more about anxiety and perfectionism. The obsessive rumination and the constant reassurance-seeking, checking in with colleagues, rereading notes, googling ethics questions late at night, those are actually maintaining the anxiety, not reducing it. I explained that every time they seek reassurance, it gives short-term relief but reinforces the belief that they can't trust their own judgment.

We started building a plan to reduce the reassurance-seeking and improve their confidence. First, we set a limit, they can check their documentation once after writing it, and that's it. No rereading later. Second, we identified their most common reassurance-seeking behaviors and came up with alternatives. Instead of texting a colleague for reassurance, they'll sit with the uncertainty for 30 minutes and see if the urge passes. Third, we worked on some cognitive reframing. I asked them to write down evidence that they're competent, feedback they've gotten, clients who've improved, times they handled tough situations well. They seemed hesitant but agreed to try.

Their homework is to practice the documentation limit this week and to start that evidence list. We'll meet again next week to see how it's going and keep working on building their self-trust.

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More About SOAP Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about SOAP notes.