SOAP Notes for Perinatal Clients: Template + Examples (2026)
Overview
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Short answer: a SOAP note for a perinatal or postpartum client has four parts. Subjective: the client’s report of mood, anxiety, sleep (including how much the baby lets her sleep), feeding, bonding, support and any intrusive or frightening thoughts since the last session. Objective: what you observed, scores such as the Edinburgh Postnatal Depression Scale (EPDS) with item 10 recorded separately, and the interventions you used. Assessment: your judgment about diagnosis, severity and change, and your risk formulation for the parent and the baby. Plan: next steps, coordination with the obstetric provider, pediatrician or prescriber, support at home and repeat measures.
The perinatal period runs from pregnancy to about a year after birth. In DSM-5-TR, the specifier “with peripartum onset” applies when a mood episode begins in pregnancy or within 4 weeks after delivery, but symptoms that start later in the first year are still common and treatable, so record when they began.
What to document in a SOAP note for perinatal clients
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Mood, anxiety, sleep, feeding, bonding, support and any intrusive thoughts since the last session | “Sleeping about 4 hours in total; partner now does the 2 a.m. feed. Still has unwanted images of the baby slipping in the bath.” |
| Objective | Observations, EPDS total and item 10, and the interventions used | “EPDS 15 (19 at intake); item 10 scored 0. Affect anxious, tearful when describing the bath images.” |
| Assessment | Diagnosis, severity and change; risk formulation for the parent and the baby | “Intrusive thoughts are unwanted and distressing, with no intent; no psychotic symptoms; acute risk to self and baby low.” |
| Plan | Next steps, coordination with medical providers, support at home and repeat measures | “Bathe the baby with partner in the room twice; EPDS every two sessions; update OB with consent.” |
Safety. Suicide is a leading cause of death in the year after birth, so ask directly at every session and record the answer, not only EPDS item 10. 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. Ask about thoughts of harming the baby and record whether they are unwanted and distressing or come with intent. Suspected postpartum psychosis, with symptoms such as confusion, hallucinations, delusions or mania, often in the first weeks after birth, is a medical emergency: call 911 or go to the nearest emergency department immediately. Marked new sleeplessness, especially with agitation or unusual beliefs, also needs prompt assessment. The National Maternal Mental Health Hotline takes calls and texts at 1-833-TLC-MAMA (1-833-852-6262). 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 Perinatal & Postpartum Clients
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for perinatal clients, focus on capturing the client’s own report of symptoms, emotional state, and any concerns related to pregnancy, childbirth, or postpartum experiences. This section should reflect the client’s perspective on triggers, mood fluctuations, and any psychosocial stressors impacting their well-being.
- Description of pregnancy-related physical symptoms as reported by the client (e.g., nausea, fatigue, contractions)
- Client’s self-reported mood changes or affective symptoms including anxiety, depression, or irritability
- Identification of specific triggers or stressors related to pregnancy or postpartum period
- Client’s concerns about fetal health, labor, delivery, or parenting abilities
- Report of sleep patterns and perceived quality of rest since last visit
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In a perinatal psychotherapy note, document your behavioral observations, mental health screening results and psychological interventions. Include medical findings only when relevant and available from the qualified clinician, naming that clinician, the source and the date; do not imply that the therapist performed an obstetric examination.
- Relevant medical findings (such as blood pressure concerns) communicated by the obstetric clinician, with source and date
- Observation of client’s affect, posture, and any signs of distress or discomfort
- Fetal-movement or pregnancy concerns reported by the client, with the referral action recorded
- Use and response to psychological interventions such as relaxation techniques, breathing exercises or cognitive restructuring
- Results of any screening tools or standardized assessments administered (e.g., Edinburgh Postnatal Depression Scale)
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
In the Assessment section for perinatal clients, synthesize subjective and objective data to form clinical impressions regarding the client’s physical and emotional status. Evaluate progress towards treatment goals and consider diagnostic possibilities related to perinatal health.
- Clinical impression of maternal mental health status, including risk for perinatal mood disorders
- Psychological impact of reported physical symptoms and the action taken to obtain obstetric assessment; attribute any conclusions about pregnancy complications to the obstetric clinician
- Assessment of client’s coping mechanisms and support system effectiveness
- Interpretation of response to therapeutic interventions applied during the session
- Summary of client’s progress or setbacks since previous visit with respect to treatment goals
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section for perinatal clients outlines the next steps in care, including treatment modifications, referrals, and client education to support maternal and fetal health. It should also include scheduling follow-ups and any homework or self-care activities assigned.
- Recommendations for continuation or adjustment of current therapeutic interventions
- Referral to specialists such as obstetricians, mental health providers, or lactation consultants as indicated
- Assignment of specific self-care or coping strategies to be practiced between sessions
- Scheduling of next appointment or follow-up visits based on clinical status
- Education topics planned for upcoming sessions, such as birth preparation or postpartum care
DAP Notes for Perinatal Clients
Alternative format for documenting perinatal clients
BIRP Notes for Perinatal Clients
Alternative format for documenting perinatal clients
Progress Notes for Perinatal Clients
Alternative format for documenting perinatal clients
SIRP Notes for Perinatal Clients
Alternative format for documenting perinatal clients
GIRP Notes for Perinatal Clients
Alternative format for documenting perinatal clients
PIE Notes for Perinatal Clients
Alternative format for documenting perinatal clients
Example SOAP note for a postpartum client (cognitive behavioral therapy)
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, 32, 9 weeks after the birth of her first child. Major depressive disorder, single episode, moderate, with peripartum onset (F32.1); symptoms began in the third trimester. Session 4 of weekly cognitive behavioral therapy (CBT), 50 minutes, by video while the baby slept. Sertraline started 3 weeks ago, prescribed and managed by her obstetrician. Treatment-plan goals: (1) bathe and change the baby without avoidance; (2) EPDS below 10.
Subjective: Client reports mood “a bit lighter” and about 4 hours of sleep in total each night; her partner now does the 2 a.m. bottle. Still has unwanted images, several times a day, of the baby slipping under the water in the bath, and has not bathed the baby since week 3; her partner does all baths. Said, “If I think it, maybe I’m a danger to her.” Feels close to the baby and enjoys feeding times. Taking sertraline as prescribed; no side effects reported. Asked directly: denies thoughts of suicide or self-harm, now and since the last session; no past attempts; no firearms in the home. Says she has never wanted to harm the baby and finds the images “horrible.” Partner and her mother are supportive.
Objective: EPDS: 15 (19 at intake); item 10 scored 0. Casually dressed, tired; affect anxious, tearful when describing the bath images, brighter when talking about feeding; speech normal; thought process linear; no hallucinations, delusions or confusion; alert and oriented. Interventions: psychoeducation that unwanted intrusive thoughts of harm are common after birth and differ from intent; cognitive restructuring of the belief that having the thought means she is dangerous (belief rated 80% before, 50% after); planned a gradual return to bathing, starting with her partner in the room; sleep protection plan reviewed.
Assessment: MDD with peripartum onset, moderate, improving: EPDS down 4 points since intake, still above 13. Intrusive harm images are unwanted, distressing and against her values, with avoidance of bathing; there is no intent, planning or psychotic feature, which fits anxious intrusive thoughts rather than a risk of acting on them. Avoidance and the belief “thinking it means I’m dangerous” maintain the anxiety; the belief loosened in session, and change at home is not yet seen. Sleep loss adds to symptoms. Risk formulation: no suicidal or self-harm thoughts, no intent to harm the baby, no psychotic symptoms, strong support at home; acute risk to self and baby judged low. Reassess every session.
Plan: Continue weekly CBT. Task chosen by client: bathe the baby with her partner in the room on 2 evenings, rating anxiety 0 to 10 before and after. Keep the partner-led 2 a.m. feed. With her written consent, send the EPDS trend to her obstetrician, who manages sertraline. Repeat EPDS every two sessions. Client and partner know the signs of postpartum psychosis and to go to the emergency department if they appear. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger. Client has the National Maternal Mental Health Hotline number.
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Tips for SOAP Notes for Perinatal & Postpartum Clients
Record EPDS item 10 separately
Write the total next to the earlier score and item 10 on its own. Any positive item 10 needs a same-day risk assessment.
Ask about thoughts of harming the baby
Record what the thoughts are, whether they are unwanted and distressing, any avoidance, and whether there is intent, so your risk formulation is clear.
Write down onset timing
Note whether symptoms began in pregnancy, in the first 4 weeks after birth or later. It affects the specifier and treatment planning.
Document sleep and support
Record total sleep, who does night feeds and who helps at home. Sleep loss and isolation are common drivers of symptoms.
Coordinate with the medical team
Note consented contact with the obstetric provider, prescriber or pediatrician. Leave medication decisions in pregnancy and breastfeeding to the prescriber.
Know the emergency signs
Record that the client and family know that suspected postpartum psychosis needs immediate emergency assessment: call 911 or go to the nearest emergency department, without waiting for a routine appointment, with a responsible adult staying with the parent and the baby kept safe.
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Further Reading
- SAMHSA — Provides resources on behavioral health and best practices for perinatal and postpartum mental health care.
- APA Documentation Guidelines — Offers detailed guidance on clinical documentation standards applicable to mental health professionals.
- NIMH (National Institute of Mental Health) — Contains research and information on perinatal mental health disorders and evidence-based treatment approaches.