How do you write a SOAP note for OCD?

Record obsessions, rituals with time or counts, avoidance and exposure practice in Subjective; observations, the Y-BOCS score and in-session exposures with SUDS ratings in Objective; your judgment about ERP response, maintaining factors and risk in Assessment; and hierarchy steps, homework and measures in Plan.

How is the Y-BOCS scored?

The Yale-Brown Obsessive Compulsive Scale has 10 core items, 5 for obsessions and 5 for compulsions, each scored 0 to 4, for a total of 0 to 40. Commonly used bands are 0–7 subclinical, 8–15 mild, 16–23 moderate, 24–31 severe and 32–40 extreme.

How do you document ERP in a progress note?

Record the hierarchy step, the exposure the client did, its length, SUDS ratings at the start and end, whether the client resisted the ritual (response prevention), and the homework exposures agreed for the week.

What is the ICD-10 code for OCD?

ICD-10-CM codes include F42.2 (mixed obsessional thoughts and acts), F42.3 (hoarding disorder), F42.4 (excoriation disorder), F42.8 (other obsessive-compulsive disorder) and F42.9 (obsessive-compulsive disorder, unspecified). Use the code that matches your diagnosis.

Should intrusive harm thoughts be documented as risk?

Document them as obsessions in the client’s words and your formulation, for example ego-dystonic thoughts the client fears and avoids. Also ask directly about suicidal thoughts and intent and record the answer, because OCD often co-occurs with depression.

SOAP Notes for OCD: Example and Template

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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: an OCD SOAP note records the client’s obsessions, rituals (with time spent or counts), avoidance and exposure practice in Subjective; your observations, the Y-BOCS score and the exposures done in session with distress (SUDS) ratings in Objective; your judgment about response to exposure and response prevention (ERP), maintaining factors and risk in Assessment; and the next steps on the exposure hierarchy and homework in Plan.

OCD progress is easiest to show with numbers: hours a day on rituals, the number of washes or checks, how far up the exposure hierarchy the client has moved, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS, 0 to 40) compared with baseline. Record reassurance-seeking and family accommodation too, because they often maintain symptoms and are part of the treatment plan.

What to document in an OCD SOAP note

What to document in each SOAP section for OCD, with fictional example wording
Section	What to document	Example wording
Subjective	Obsessions and rituals since the last session, with time or counts	“Contamination fears most days; washing about 20 times a day (about 35 at intake), 1–2 minutes each.”
Subjective	Exposure practice completed and reassurance-seeking	“Completed 5 of 7 planned ERP practices; still asks partner ‘Are you sure it’s clean?’ several times a day.”
Objective	Observations, Y-BOCS and in-session exposure with SUDS	“Hands red and dry. Y-BOCS 22 (28 at intake). Touched the clinic door handle, no washing; SUDS 75 to 40 in 30 minutes.”
Assessment	Response to ERP, maintaining factors and progress toward goals	“Responding to ERP (washing down about 40%, Y-BOCS down 6); reassurance-seeking remains a maintaining factor.”
Assessment	Risk screen, distinguishing intrusive thoughts from intent	“Denied suicidal thoughts and self-harm; no safety concerns identified.”
Plan	Next hierarchy steps, homework, family plan and measures	“Daily exposures at SUDS 50–60 with response prevention; partner to stop giving reassurance; repeat Y-BOCS at session 12.”

Intrusive harm or suicide-themed obsessions are unwanted and are not the same as suicidal intent, but OCD often co-occurs with depression. Ask about suicidal thoughts directly and, if present, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, 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 Obsessive-Compulsive Disorder

Subjective

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

When documenting the Subjective section for OCD, capture the client's personal report of their obsessions, compulsions, emotional state, and any identified triggers or distress related to their symptoms.

Client's detailed description of intrusive thoughts or obsessions experienced since the last session
Client's report of compulsive behaviors or rituals and their frequency/duration
Identification of specific triggers or situations that exacerbate OCD symptoms
Client's mood and affect related to OCD symptom burden, including feelings of anxiety, shame, or frustration
Client's perception of how OCD symptoms impact daily functioning and quality of life

Objective

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

In the Objective section for OCD, record observable behaviors, clinical assessments, and therapeutic interventions applied during the session to objectively measure symptom presentation and treatment adherence.

Clinician’s observation of client’s anxiety levels and physical signs of distress during session
Administration and scoring of standardized OCD symptom rating scales (e.g., Y-BOCS)
Description of exposure and response prevention (ERP) exercises conducted or practiced in session
Documentation of cognitive-behavioral therapy (CBT) techniques utilized during the session
Noting client’s engagement and participation in therapeutic activities or homework review

Assessment

Provide clinical interpretation, diagnostic impressions, and progress evaluation

The Assessment section should synthesize clinical impressions based on subjective reports and objective findings to evaluate OCD symptom severity, treatment progress, and any diagnostic or therapeutic considerations.

Clinical impression of current OCD symptom severity and changes since last session
Evaluation of client’s response to ERP and other CBT interventions
Assessment of co-occurring mood or anxiety symptoms impacting OCD treatment
Consideration of any differential diagnoses or comorbid conditions influencing presentation
Summary of client’s insight and motivation regarding OCD management and therapy adherence

Plan

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

The Plan section outlines the next steps in OCD treatment, including therapy goals, homework assignments, treatment modifications, and any recommended referrals or scheduling.

Schedule and focus of next session with specific OCD treatment targets
Assignment of tailored homework, such as ERP tasks or cognitive restructuring exercises
Modification of treatment approach based on current progress or barriers identified
Referral to psychiatry or support groups if medication evaluation or additional support is needed
Discussion and planning for coping strategies and relapse prevention techniques