SOAP Notes for Adjustment Disorder: Example and Template
Overview
This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
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Short answer: an adjustment disorder SOAP note links the client’s symptoms to an identifiable stressor and shows how they are changing. Subjective: the stressor, when it began, the symptoms and their effect on work, school or relationships, in the client’s words. Objective: appearance, affect, behavior in session and measure scores. Assessment: whether the presentation still fits adjustment disorder (subtype, timeline, other diagnoses considered), risk, and progress toward goals. Plan: coping and problem-solving work, supports, referrals and the next session.
In DSM-5-TR, adjustment disorder requires emotional or behavioral symptoms that begin within 3 months of an identifiable stressor and cause marked distress out of proportion to the stressor (taking context and culture into account) or significant impairment. The symptoms do not meet criteria for another mental disorder, are not just a worsening of an existing one, are not normal bereavement and are not better explained by prolonged grief disorder, and once the stressor or its consequences have ended they do not last more than another 6 months. Because the diagnosis depends on timing, record the stressor and its dates. The tables show the subtypes and what goes in each section.
| Subtype (DSM-5-TR specifier) | ICD-10-CM | Predominant symptoms |
|---|---|---|
| With depressed mood | F43.21 | Low mood, tearfulness or hopelessness |
| With anxiety | F43.22 | Nervousness, worry, jitteriness or separation anxiety |
| With mixed anxiety and depressed mood | F43.23 | A combination of depression and anxiety |
| With disturbance of conduct | F43.24 | Behavior that violates others’ rights or social norms |
| With mixed disturbance of emotions and conduct | F43.25 | Emotional symptoms and a disturbance of conduct |
| Unspecified | F43.20 | Reactions that do not fit one of the specific subtypes |
What to document in an adjustment disorder SOAP note
| SOAP section | What to document | Example wording |
|---|---|---|
| Subjective | The stressor, when it began and whether it is ongoing | “Laid off 7 weeks ago; still looking for work; severance ends next month.” |
| Subjective | Symptoms since the last session in the client’s words, and their effect on functioning | “Low mood most days and worry about money at night. Sent 3 job applications (none the week before); stopped going to the gym.” |
| Objective | Appearance, affect, behavior in session and measure scores with dates | “Tearful discussing finances, brighter describing a phone screen. PHQ-9 today 11 (15 at intake); GAD-7 9 (13 at intake).” |
| Assessment | Fit with adjustment disorder (subtype, timeline, other diagnoses considered), risk and progress | “Symptoms began within 2 weeks of the layoff and still fit adjustment disorder with mixed anxiety and depressed mood; criteria for major depressive disorder not met on review. Denied suicidal thoughts.” |
| Plan | Interventions used, coping and problem-solving steps, supports, referrals and the next session | “Structured problem solving on finances; 3 applications and a career-center resume review this week; next session in 1 week.” |
If the client reports suicidal thoughts, increased alcohol or drug use, worsening symptoms, or symptoms that now meet criteria for another disorder (for example major depressive disorder, or PTSD after a traumatic stressor), document the details, your assessment and what you did, and update the diagnosis and treatment plan, following your organization’s protocol.
How to Document SOAP Notes for Adjustment Disorders
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for adjustment disorder, focus on the client’s own report of symptoms, emotional state, and specific stressors or triggers that have contributed to their current condition.
- Client describes recent stressors or life changes precipitating emotional distress
- Client reports mood symptoms such as sadness, anxiety, irritability, or hopelessness
- Client identifies impact of symptoms on daily functioning and relationships
- Client expresses subjective perception of coping abilities and emotional resilience
- Client notes duration and intensity of emotional or behavioral changes since stressor onset
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In the Objective section for adjustment disorder, document observable clinical signs, behavioral observations, and any therapeutic techniques or assessments administered during the session.
- Clinician observes client’s affect, noting congruence or incongruence with reported mood
- Documentation of client’s psychomotor activity, eye contact, and speech patterns
- Use and client response to therapeutic modalities such as relaxation techniques or cognitive restructuring
- Administered standardized scales or screening tools relevant to adjustment disorder symptoms
- Observed changes in client’s engagement, motivation, or insight during the session
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
The Assessment section for adjustment disorder should capture the clinician’s diagnostic impressions, evaluation of symptom severity and progress, and consideration of differential diagnoses or complicating factors.
- Clinical impression of adjustment disorder subtype and symptom predominance
- Evaluation of client’s progress toward therapeutic goals since last session
- Consideration of alternative or comorbid diagnoses impacting treatment planning
- Assessment of client’s insight into stressors and emotional responses
- Analysis of client’s coping strategies effectiveness and need for intervention adjustment
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
In the Plan section for adjustment disorder, outline the proposed treatment steps including therapeutic interventions, homework assignments, referrals, and scheduling to support symptom reduction and improved functioning.
- Schedule follow-up sessions focusing on stress management and coping skills development
- Assign homework such as journaling emotions or practicing relaxation exercises
- Modify treatment approach based on client’s response and symptom progression
- Refer client to specialized services if additional support is indicated (e.g., psychiatry, social work)
- Establish safety plan or crisis intervention steps if risk factors emerge
DAP Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
BIRP Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
Progress Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
SIRP Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
GIRP Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
PIE Notes for Adjustment Disorder
Alternative format for documenting adjustment disorder
Adjustment disorder SOAP note example
Fictional documentation example, not treatment guidance. Adapt it to the session you actually conducted and your organization’s requirements.
Subjective: Fictional adult client, session 5; adjustment disorder with mixed anxiety and depressed mood (F43.23), acute, diagnosed at intake. Stressor: laid off from his job as a warehouse supervisor 7 weeks ago; symptoms began about 2 weeks later. Treatment-plan goals: up by 8 a.m. on weekdays, and at least 3 job applications a week. Client reported low mood on most days and worry about money, mainly at night, with sleep onset over an hour on 3 of 7 nights. Sent 3 applications this week (none the week before) and was up by 8 a.m. on 4 of 5 weekdays. Has stopped going to the gym. Client stated: “I keep thinking I let my family down.” Reports drinking 1–2 beers on weekends, unchanged since before the layoff.
Objective: Casually dressed and well groomed. Tearful when discussing finances; brighter and more animated when describing a phone screen scheduled for next week. Speech normal in rate and volume. Engaged throughout. PHQ-9 today 11 (15 at intake); GAD-7 today 9 (13 at intake).
Assessment: Symptoms remain linked to the job loss, began within 3 months of it and are improving: applications and the morning routine are moving toward the goals, and PHQ-9 and GAD-7 scores are lower than at intake. On review, the presentation does not meet criteria for major depressive disorder or generalized anxiety disorder and still fits adjustment disorder with mixed anxiety and depressed mood. Screened for suicidal thoughts: client denied current or past thoughts. No safety concerns identified.
Plan: Used structured problem solving on the money worry: the client listed options and chose to call the state unemployment office and draft a monthly budget with his wife. Practiced scheduling a 10-minute “worry time” in the early evening. Client will send 3 applications, book a resume review at the local career center, go to the gym twice and use worry time on weeknights. Repeat the PHQ-9 and GAD-7 in four weeks; reassess the acute or persistent specifier if symptoms continue toward 6 months. Next session in one week.
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Tips for SOAP Notes for Adjustment Disorders
1. Name the stressor and the dates
Record what the stressor is, when it began, when symptoms began and whether the stressor is ongoing or over. The diagnosis depends on this timeline, so keep it current in the note rather than only at intake.
2. Match the subtype to the predominant symptoms
Choose the specifier (with depressed mood, with anxiety, mixed, with disturbance of conduct, or mixed emotions and conduct) that fits the symptoms you documented, and update the diagnosis if the picture changes.
3. Revisit the diagnosis at each review
Adjustment disorder is not used when symptoms meet criteria for another specific disorder, such as major depressive disorder or PTSD, or are better explained by normal bereavement or prolonged grief disorder. Record that you considered these.
4. Track function and measures consistently
Record a few functional markers tied to the goals, such as days at work, applications sent or routines kept, and, if you use measures such as the PHQ-9 or GAD-7, the score and date at set points.
5. Screen for risk and substance use
Ask directly about suicidal thoughts and about any change in alcohol or drug use, and record the answers. A stressor-linked diagnosis does not mean low risk.
6. Use the duration specifier correctly
Acute means symptoms have lasted less than 6 months; persistent (chronic) means 6 months or more, which happens when the stressor or its consequences continue. Once the stressor and its consequences end, symptoms should not last more than another 6 months; if they do, reassess.
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Further Reading
- DSM-5-TR — Provides the diagnostic criteria and clinical features essential for accurately assessing Adjustment Disorders.
- APA Documentation Guidelines — Offers detailed guidance on clinical documentation practices, including SOAP note formatting and content.
- SAMHSA — Contains resources on mental health treatment standards and best practices relevant to Adjustment Disorders.