What should a SOAP note for bipolar II disorder include?

The client’s report of mood, sleep, energy, hypomanic and depressive symptoms and medication use (Subjective); your observations, mood chart data, scale scores and what you did in session (Objective); the current phase, warning signs, adherence and risk (Assessment); and the next session, self-monitoring, prescriber contact and warning-sign plan (Plan).

What is the difference between bipolar I and bipolar II?

Bipolar I requires at least one manic episode. Bipolar II requires at least one hypomanic episode (at least 4 consecutive days, not severe enough to cause marked impairment or hospitalization, and without psychotic features) and at least one major depressive episode, with no history of mania. If a client with bipolar II has a manic episode, the diagnosis changes to bipolar I.

What ICD-10-CM code is used for bipolar II disorder?

F31.81 is bipolar II disorder. Code what your assessment supports, and record the current episode type and course in the note.

How do you document hypomania in a therapy note?

Record the specific symptoms the client reports or you observe (elevated or irritable mood, more energy, less need for sleep, racing thoughts, talkativeness, risky behavior), when they started and how many days they lasted, how they affected functioning, and what you did, such as contacting the prescriber.

How often should suicide risk be assessed in bipolar II?

Suicide risk is high in bipolar disorder, so many clinicians ask at every session and record the answer. Record a full assessment and risk formulation whenever the client reports suicidal thoughts, and follow your organization’s policy.

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

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Overview

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Short answer: a SOAP note for bipolar II disorder tracks both poles. Subjective: the client’s report of mood since the last session, sleep, energy, any days that felt “up” (less need for sleep, racing thoughts, more spending or risk-taking) and depressive symptoms, plus medication use as reported. Objective: what you observed (affect, speech rate, psychomotor activity, thought process), mood chart data and scale scores, and what you did in session. Assessment: the current phase (depressed, hypomanic, mixed features or euthymic), early warning signs, adherence and risk. Plan: the next session, self-monitoring, contact with the prescriber and what the client will do if warning signs appear.

Bipolar II means at least one hypomanic episode and at least one major depressive episode, with no history of a manic episode. Most of the time people with bipolar II spend unwell is spent depressed, so notes often focus on depression, but each note should still say whether you checked for hypomania.

What to document in a bipolar II SOAP note

Bipolar II details to document in a SOAP note, with fictional example wording
Item	What to document	Example wording
Mood chart and sleep	Daily mood ratings, hours of sleep and any nights of little sleep without feeling tired	“Mood chart: −2 to 0 most days; sleep 6.5 to 7.5 h; no short-sleep nights.”
Hypomania check	Elevated or irritable mood, more energy, less need for sleep, racing thoughts, talkativeness, risky spending or sex, and how many days they lasted	“Denies decreased need for sleep, racing thoughts or impulsive spending.”
Depression	Low mood, loss of interest, energy, sleep and appetite change, with a scale score	“PHQ-9 11 (16 four weeks ago).”
Medication	What the client reports taking, missed doses, side effects and contact with the prescriber; note that you are recording the client’s report	“Reports taking lamotrigine as prescribed; missed 1 dose.”
Triggers and routine	Sleep disruption, shift work, travel, conflict, substance use and daily routine	“Bedtime varied by 3 h on weekends.”
Risk	Suicide risk at every session, plus risk from impulsive behavior during hypomania	“Denies suicidal thoughts, intent or plan; no firearms at home.”

Safety. Suicide risk is high in bipolar disorder, especially during depressive and mixed episodes, so ask directly at every session and record the answer. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. Contact the prescriber promptly if hypomanic symptoms appear after an antidepressant is started or increased, or if symptoms escalate toward mania or psychosis. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.

How to Document SOAP Notes for Bipolar II Disorder

Subjective

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

When documenting the Subjective section for bipolar disorder II, capture the client's personal report of mood fluctuations, symptom severity, and any perceived triggers or stressors affecting their emotional state.

Client’s description of recent periods of hypomanic symptoms including elevated mood, increased energy, or impulsivity
Client’s report of depressive episodes such as feelings of sadness, anhedonia, or low motivation
Identification of any psychosocial or environmental triggers contributing to mood changes
Client’s self-reported sleep patterns and changes in appetite during mood episodes
Client’s insight and awareness regarding mood swings and their impact on daily functioning

Objective

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

In the Objective section for bipolar disorder II, record observable behaviors, clinical findings, and results from standardized assessments or monitoring tools used during the session.

Clinician’s observation of client’s affect, mood congruence, and psychomotor activity
Use and outcomes of mood rating scales or symptom checklists administered during the visit
Documentation of sleep hygiene and activity level as observed or reported during the session
Recording of cognitive functioning, including attention, memory, and thought process clarity
Details of therapeutic interventions applied such as cognitive behavioral techniques or psychoeducation provided

Assessment

Provide clinical interpretation, diagnostic impressions, and progress evaluation

The Assessment section should synthesize clinical impressions, evaluate the client’s progress, and refine diagnostic understanding based on subjective and objective data related to bipolar disorder II.

Evaluation of mood episode patterns and severity compared to previous sessions
Clinical impression of current stability or risk for mood episode relapse
Assessment of treatment adherence and client’s response to medication or therapy
Consideration of comorbid conditions impacting symptom presentation or treatment outcomes
Client’s engagement and emotional response to therapeutic interventions and session content

Plan

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

Document the treatment plan focused on managing bipolar disorder II, including therapeutic goals, medication adjustments, referrals, and scheduling of follow-up care.

Outline of specific therapeutic goals targeting mood stabilization and symptom management
Recommendation for medication review or coordination with prescribing provider if indicated
Assignment of homework or self-monitoring tasks such as mood charting or sleep tracking
Plan for referral to psychiatry, support groups, or other specialized services as needed
Scheduling of next session and contingency planning for mood episode exacerbations