SOAP Example
Jim Doe
Aug 30, 01 Ind 1430 to 1550
S/O: “I’m doing better but
I was really ticked at my wife all week”. Reports more arguments but fewer explosive episodes.
SUD=5. Discussed family of origin for patterns similar to
this. Examined automatic
thoughts. Taught thought detection and thought selection. Restless and interrupted me through out
session.
A: Pt remaining focused on
Tx Plan. Improvement over last session SUD=2. Errors in
thinking contribute to low frustration tolerance, over reaction and anger.
nP: Remain on Tx plan issues with wife.