How do you write a SOAP note for schizophrenia?

In Subjective, record hallucinations and beliefs with frequency, distress and coping, plus function, sleep, substance use and medication as the client reports it. In Objective, record a brief mental status exam and any rating scale. In Assessment, give symptom severity, function, insight, progress and a risk formulation. In Plan, record coping work, coordination with the prescriber and supports, the crisis plan and the next session.

What is the ICD-10 code for schizophrenia?

DSM-5-TR codes schizophrenia as F20.9 in ICD-10-CM. Related psychotic disorders have their own codes, for example F25.0 and F25.1 for schizoaffective disorder, bipolar and depressive types, and F23 for brief psychotic disorder. Use the code that matches your assessment and the payer’s rules.

How do you document hallucinations in a progress note?

Record the type, how often they occur, their general content, whether they comment or give commands, how distressing they are, how much the client believes them and how the client copes. Use the client’s words where helpful and record whether you observed the client responding to internal stimuli.

What rating scales are used for schizophrenia?

Common clinician-rated scales include the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS), which requires training. Many therapists also use simple 0–10 ratings of voice distress and belief conviction. Record the scale, score and date, and repeat it at set points.

SOAP Notes for Schizophrenia: Template + Examples (2026)

Q: What therapy is used for schizophrenia?

Psychosocial treatments used alongside medication include cognitive behavioral therapy for psychosis, family psychoeducation, social skills training, supported employment and, for a first episode, coordinated specialty care. Whichever you use, name the specific technique in the note and link it to a functional goal.

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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 schizophrenia records the client’s report of hallucinations, unusual beliefs, mood, sleep, substance use and daily functioning, and what they report about medication and side effects (Subjective); a brief mental status exam and any rating scale (Objective); symptom severity, functioning, progress toward goals and a risk formulation (Assessment); and the plan, including coordination with the prescriber and supports (Plan). Describe symptoms in the client’s own words and record how much they interfere with life, not only whether they are present.

Schizophrenia (F20.9 in ICD-10-CM) requires continuous signs of disturbance for at least 6 months, including at least 1 month of active-phase symptoms (less if successfully treated): two or more of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms, at least one of them delusions, hallucinations or disorganized speech. The other months may include milder prodromal or residual symptoms, and functioning must have dropped, after mood disorders, substances and medical conditions have been ruled out as the cause. Psychosocial treatments used alongside antipsychotic medication include cognitive behavioral therapy for psychosis (CBTp), family psychoeducation, social skills training, supported employment and, for a first episode, coordinated specialty care. For voices, record frequency, distress, whether they comment or give commands, and how the client copes. Write “a person with schizophrenia” rather than “a schizophrenic,” and avoid words like “bizarre” without describing what you observed. The table shows what goes in each section.

What to document in a schizophrenia SOAP note

What to document in each SOAP section, with fictional example wording
Section	What to document	Example wording
Subjective	Voices and beliefs: frequency, content in general terms, distress and coping	“Hears a critical male voice most evenings, distress 5/10 (8/10 at intake); no commands. Used humming and going for a walk.”
Subjective	Function, sleep and substance use	“Attended the day program 4 of 5 days; sleeping about 8 hours; no cannabis for 3 weeks.”
Subjective	Medication and side effects, as the client reports them	“Taking monthly injection as scheduled; reports feeling restless in the legs since last week.”
Objective	Mental status exam and measures	“Affect restricted; thought process mostly linear with occasional tangential replies; responding to voices not observed. BPRS 38 (48 at intake).”
Assessment	Symptom severity, function, insight and a risk formulation	“Positive symptoms reduced; functioning improving. Acute risk to self and others judged low, with the factors behind that judgment.”
Plan	Coping skills, coordination with consent, supports and next session	“With consent, inform the psychiatrist about the reported restlessness today; continue CBTp coping plan; next session in 1 week.”

Suicide risk is elevated in schizophrenia, especially early in the illness and after a hospital stay, so screen at every session. If the client reports command hallucinations to harm themselves or others, intent to act, a sharp rise in symptoms, or not eating or sleeping, act as your protocol requires (for example a full risk assessment, same-day contact with the treatment team, or a higher level of care) and document what you did. Restlessness, stiffness or new movements may be medication side effects; record what the client reports and inform the prescriber, with consent, rather than changing treatment yourself.

How to Document SOAP Notes for Schizophrenia & Psychotic Disorders

Subjective

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

When documenting the Subjective section for schizophrenia, capture the client’s self-reported experiences including symptom descriptions, mood states, and any perceived triggers or stressors that influence their condition.

Report of auditory or visual hallucinations including frequency and content
Description of delusional beliefs or suspicious thoughts as experienced by the client
Client’s mood and affect as described during the session
Identification of recent stressors or environmental triggers contributing to symptom exacerbation
Client’s insight into their illness and medication adherence challenges

Objective

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

In the Objective section for schizophrenia, document observable clinical signs, mental status examination findings, and any therapeutic interventions or assessments conducted during the encounter.

Mental status exam findings including appearance, behavior, and speech patterns
Observation of thought process abnormalities such as tangentiality or loosening of associations
Record of affect congruence or blunted/flat affect observed during the session
Documentation of any cognitive testing or symptom rating scales administered
Description of therapeutic modalities applied, such as cognitive behavioral techniques or social skills training

Assessment

Provide clinical interpretation, diagnostic impressions, and progress evaluation

The Assessment section for schizophrenia should synthesize clinical impressions based on subjective and objective data, evaluate treatment progress, and consider diagnostic clarifications or complications.

Clinical impression regarding current symptom severity and stability
Client-reported medication effects and side effects, recorded for coordination with the prescriber
Assessment of client’s insight and judgment since last visit
Consideration of any co-occurring psychiatric or medical conditions impacting schizophrenia
Summary of client’s engagement and response to therapeutic interventions

Plan

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

In the Plan section for schizophrenia, outline therapeutic goals, referrals, follow-up sessions and coordination with the prescriber about reported medication effects or concerns. Medication adjustments are the prescriber’s responsibility.

Coordination with the prescriber about medication, side effects and any laboratory tests, with consent
Scheduling of psychotherapy or psychoeducation sessions focused on symptom management
Referral to social services or vocational rehabilitation as needed
Assignment of specific homework or coping strategies to practice between sessions
Record reported or observed possible side effects and coordinate with the prescriber about any monitoring or laboratory tests they recommend