SOAP Notes for Depression
How to write a SOAP note for depression: what goes in each section, how to record PHQ-9 scores and suicide risk, and how to show progress, with a fictional behavioral activation example.
Quick Answer
A SOAP note for depression records the client’s report of mood, sleep, energy, interest and activities (Subjective), your observations and the PHQ-9 score including item 9 (Objective), your judgment about severity, change and suicide risk (Assessment), and the next steps (Plan). Tie progress to scores and to what the client is doing again in daily life.
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 depression records Subjective: the client’s report of mood, interest or pleasure, sleep, appetite, energy, concentration and activities since the last session. Objective: your observations (appearance, psychomotor activity, affect), the PHQ-9 score and item 9, and a suicide risk check. Assessment: severity, change since intake, what is helping, and risk. Plan: interventions, practice, coordination with any prescriber, and when you will repeat the PHQ-9.
Insurers look for medical necessity: current symptoms, how they affect work, relationships or self-care, and a plan tied to treatment goals. Scores help, but describe daily functioning too; a lower score alone does not show a goal is met.
What to document in a depression SOAP note
| Item | What to document | Example wording |
|---|---|---|
| Symptoms | Mood, interest, sleep, appetite, energy, concentration, guilt or worthlessness, with frequency | “Low mood most days; sleeping 9 to 10 hours; low energy.” |
| PHQ-9 | Total (0 to 27) and severity band, item 9, and the comparison score | “PHQ-9 13 (moderate), intake 18; item 9 = 0.” |
| Functioning | Work, relationships, self-care and activities the client stopped or restarted | “Walked 3 times; called brother; has not returned to choir.” |
| Suicide risk | Direct questions, history, means, protective factors and your risk judgment | “Denies suicidal thoughts, intent or plan; no past attempts; no firearms.” |
| Interventions | The approach used and what you did, such as activity scheduling | “Behavioral activation: reviewed activity and mood log; planned next steps.” |
| Medication and coordination | Medication as the client reports it, the prescriber, and any coordination with consent | “Takes sertraline prescribed by PCP; update sent to PCP with consent.” |
Safety. Ask about suicide directly every session, and act on any positive PHQ-9 item 9 the same day with a full assessment. 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. 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 Depression
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for depression, capture the client’s self-reported mood, emotional state, and any depressive symptoms they experience. Include their personal concerns, perceived triggers, and descriptions of mood fluctuations or affect.
- Report of current mood and predominant emotional state (e.g., sadness, hopelessness)
- Description of sleep patterns and changes noted by the client
- Client’s account of appetite changes or weight fluctuations
- Identification of specific stressors or triggers contributing to mood changes
- Client’s self-assessment of energy levels and motivation
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In the Objective section for depression, document observable clinical signs, behavioral presentations, and results from any standardized assessments or rating scales administered during the session.
- Clinician’s observation of psychomotor activity (e.g., agitation, retardation)
- Noted facial expression, eye contact, and overall affect congruence
- Results from depression screening tools or symptom severity scales
- Documentation of participation and engagement in therapeutic activities
- Physical signs potentially related to depression (e.g., hygiene, posture)
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
The Assessment section should synthesize clinical impressions based on collected subjective and objective data, evaluating symptom progression, diagnostic clarity, and client responsiveness to interventions for depression.
- Clinical impression of depression severity and subtype (e.g., major depressive disorder, dysthymia)
- Evaluation of symptom changes since last session or baseline
- Assessment of risk factors such as suicidal ideation or self-harm tendencies
- Client’s insight and attitudes toward treatment and symptom management
- Consideration of differential diagnoses or comorbid conditions affecting depression
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
In the Plan section for depression, outline the next therapeutic steps, including treatment adjustments, client homework assignments, referrals, and scheduling, to support ongoing management and recovery.
- Schedule and frequency of upcoming therapy sessions
- Assignment of specific homework or coping strategies for mood regulation
- Modification or introduction of pharmacological or psychotherapeutic interventions
- Referral to additional resources such as psychiatry, support groups, or social services
- Plan for monitoring and follow-up on safety concerns or symptom escalation
Example SOAP note for depression (behavioral activation session)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 52, major depressive disorder, recurrent, moderate (F33.1). Session 5 of weekly 50-minute behavioral activation therapy.
Subjective: Client completed 4 of 6 planned activities: walked 3 times and called his brother. Mood ratings on his log were 6 of 10 on walk days and 3 of 10 on other days. Sleeping 9 to 10 hours a night with low energy in the mornings. Has not returned to his church choir, which he stopped 4 months ago. Reports taking sertraline daily as prescribed by his primary care physician (PCP), with no side effects he has noticed.
Objective: PHQ-9: 13 (moderate), down from 18 at intake; item 9 = 0. Casually dressed and groomed; mild psychomotor slowing; affect constricted, brighter when describing the walks. Thought process linear. Asked directly about suicide: denies thoughts of death or suicide, intent or plan; no past attempts; no firearms at home; no stockpiled medication.
Assessment: Major depressive disorder, recurrent, moderate, improving: PHQ-9 down 5 points since intake, and the activity log links walks with better mood, which supports continuing behavioral activation. Oversleeping, low morning energy and withdrawal from the choir continue, so social and daily functioning are only partly improved. Acute suicide risk judged low: no current suicidal thoughts, intent or plan, no past attempts, no firearm access; protective factors include his brother and his faith community. Reassess each session and the same day if item 9 is positive.
Plan: Continue weekly behavioral activation. Keep the walks and add a graded step toward choir: attend the first 30 minutes of next week’s rehearsal. Set a fixed wake time of 7:30 a.m. With the client’s written consent, send his PCP a brief update with today’s PHQ-9; medication questions go to the PCP. Repeat the PHQ-9 next session. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger.
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Tips for SOAP Notes for Depression
Score and describe
Record the PHQ-9 total and band, and describe what the client is doing again in daily life. Scores alone do not show function.
Always record item 9
Write the item 9 answer every time you give the PHQ-9, and record the full assessment if it is positive.
Ask about suicide directly
Record the questions you asked and the answers, plus history, means and protective factors, then your risk judgment.
Link activities to mood
In behavioral activation, record planned versus completed activities and the client’s mood ratings so the link is visible.
Stay in scope on medication
Record medication as the client reports it and the prescriber. Send medication questions to the prescriber.
Show medical necessity
Connect symptoms to their effect on work, relationships or self-care and to the goals in the treatment plan.
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Further Reading
- DSM-5-TR — Provides standardized diagnostic criteria essential for accurate assessment and documentation of depression in clinical notes.
- NIMH (National Institute of Mental Health) — Offers authoritative information on depression symptoms, treatment options, and research to inform clinical documentation.
- APA Documentation Guidelines — Details best practices for clinical documentation, including SOAP notes, tailored to mental health professionals.