SOAP Notes for Bipolar Disorder: Template + Examples (2026)

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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: a SOAP note for bipolar disorder records the client’s report of mood, sleep, energy and early warning signs since the last session, and what they report about medication (Subjective); your observations of mood, speech, thought process and activity, plus mood ratings (Objective); the current mood state, progress toward goals and a risk formulation (Assessment); and the plan, including the relapse prevention plan and coordination with the prescriber (Plan). Sleep and warning signs matter most, because a drop in the need for sleep is often the first sign of a manic or hypomanic episode.

Bipolar I disorder involves at least one manic episode; bipolar II involves at least one hypomanic and one major depressive episode, with no manic episode. ICD-10-CM codes (F31.x) describe the current episode and its severity, so the assessment should state the current or most recent episode, for example bipolar disorder, current episode depressed, moderate (F31.32). Psychotherapies used with medication include psychoeducation, interpersonal and social rhythm therapy (IPSRT), family-focused therapy and CBT. Suicide risk is higher in bipolar disorder, particularly during depressive and mixed episodes, so screen at every session. The table shows what goes in each section.

What to document in a bipolar disorder SOAP note

What to document in each SOAP section, with fictional example wording
Section	What to document	Example wording
Subjective	Mood, sleep and energy since the last session, from the mood chart	“Mood chart: mood 3 to 4 out of 10 most days; sleeping 8 to 9 hours; low energy, missed 1 day of work.”
Subjective	Early warning signs of mania or hypomania, asked about directly	“Denies reduced need for sleep, racing thoughts, increased spending or taking on new projects.”
Subjective	Medication, as the client reports it	“Taking lithium and quetiapine as prescribed by her psychiatrist; reports mild thirst; blood test due next week.”
Subjective	Current and recent suicidal thoughts, plan, intent, history and access to means	“Passive thoughts twice this week; none today. Denies plan, intent, preparation or past attempts. Prescribed medication at home, no firearm access; means-safety steps in the plan.”
Objective	Appearance, speech, thought process and activity, plus measures	“Speech normal rate; psychomotor slowing; thought process linear. PHQ-9 15. Altman Self-Rating Mania Scale 2.”
Assessment	Current mood state, progress and a risk formulation	“Current episode depressed, moderate; no signs of mixed features. Acute suicide risk judged low, with the factors behind that judgment.”
Plan	Relapse prevention plan, social rhythm goals, coordination and next session	“Fixed wake time 7 a.m.; safety plan reviewed, 988 included; with consent, update the psychiatrist on mood and passive ideation; next session in 1 week.”

If the client reports suicidal thoughts with intent or a plan, or signs of a manic episode such as several nights of little sleep, risky behavior, or psychotic symptoms, act as your protocol requires (for example a full risk assessment, same-day contact with the prescriber, or a higher level of care) and document what you did. Record what the client reports about medication, side effects and blood tests, and leave medication decisions to the prescriber. If family members are part of the relapse prevention plan, record the client’s consent to involve them.

How to Document SOAP Notes for Bipolar Disorder

Subjective

Record the client's reported symptoms, concerns, mood, and perspective in their own words

When documenting the Subjective section for bipolar disorder, capture the client's self-reported mood states, behavioral changes, and symptom fluctuations, including any triggers or stressors that may influence their mood episodes.

Describe recent mood episodes as reported by the client (mania, hypomania, depression).
Document client’s report of sleep patterns and changes in energy levels.
Note any self-identified triggers or stressors contributing to mood instability.
Record client’s description of changes in thought content, such as racing thoughts or feelings of hopelessness.
Capture client’s insight and perception of their current mood and affective state.

Objective

Document clinical observations, affect, behavior, appearance, and measurable data

In the Objective section for bipolar disorder, provide clinician-observed signs, behavioral assessments, and any administered rating scales or diagnostic tools that objectively evaluate mood and functioning.

Observe and document client’s psychomotor activity (e.g., agitation or retardation).
Record clinician’s assessment of speech patterns (e.g., pressured or slowed speech).
Include results from mood rating scales (e.g., Young Mania Rating Scale, PHQ-9).
Note any observed changes in affect congruence and appropriateness.
Detail use of collateral information or reports from family/support system if available.

Assessment

Provide clinical interpretation, diagnostic impressions, and progress evaluation

The Assessment section for bipolar disorder should synthesize clinical findings to update diagnostic impressions, evaluate treatment response, and assess risk factors or co-occurring conditions.

Provide current diagnostic impression including mood episode classification and severity.
Evaluate client’s progress toward mood stabilization and symptom management goals.
Assess risk for self-harm, suicide, or impulsive behaviors based on current presentation.
Interpret client’s engagement and response to therapeutic interventions.
Consider need for differential diagnosis or assessment of comorbid psychiatric conditions.

Plan

Outline treatment strategy, interventions, homework, and follow-up schedule

In the Plan section for bipolar disorder, outline psychotherapy goals, mood and risk monitoring, referrals, follow-up and coordination with the prescriber about medication concerns. Medication decisions are the prescriber’s responsibility.

Record medication adherence and side effects as the client reports them, and any coordination with the prescriber, with consent.
Identify targeted psychotherapeutic interventions and homework assignments.
Schedule follow-up appointments and outline frequency of mood monitoring.
Recommend referrals for additional support services (e.g., psychiatry, social work).
Plan crisis management strategies and safety planning as needed.