• Home
  • Store
    • Newsletter Subscriptions
    • Multimedia
    • Books
    • eBooks
    • ABPN SA Courses
    • Social Work Courses
  • CME Center
  • Multimedia
    • Podcast
    • Webinars
    • Blog
    • Psychiatry News Videos
    • Medication Guide Videos
  • Newsletters
    • General Psychiatry
    • Child Psychiatry
    • Addiction Treatment
    • Hospital Psychiatry
    • Geriatric Psychiatry
    • Psychotherapy and Social Work
  • FAQs
  • Med Fact Book App
  • Log In
  • Register
  • Welcome
  • Sign Out
  • Subscribe
Home » The Humble Progress Note

The Humble Progress Note

July 1, 2005
Daniel Carlat, MD
From The Carlat Psychiatry Report
Issue Links: Editorial Information | PDF of Issue
Daniel Carlat, MD Dr. Carlat has disclosed that he has no significant relationships with or financial interests in any commercial companies pertaining to this educational activity.

By definition, a “progress note” should be a written record of the degree of our patients’ progress. We can all agree on this much, and this is pretty much where the agreement ends.

TCR has recently made an effort to assess variability in progress notes for psychopharm visits, mainly by talking to colleagues. The variability is extreme.

Some psychiatrists subscribe to the Hemingway style of progress notes – functional, spare, but not without a certain kind of elegance: “Improved. No side effects. Continue meds.”

Others favor Dostoevsky, in which each note is a fascinating and complete character study, replete with extended verbatim quotes. Most of us fall somewhere in between, and presumably we are all doing the right thing by our patients.
Some psychiatrists prefer Hemingway; others, Dostoevsky.

Unlike most articles in TCR, we can offer no empirical studies to guide us in figuring out the “answer.” To our knowledge, comparative studies of different progress note styles have yet to be conducted. Thus, we must resort to a common sense approach as we zero in on recommendations for your practice.

As our framework, we’ll use the “SOAP” format – Subjective, Objective, Assessment, Plan. We all learned this in medical school, and it is a useful template for our notes, even though there may be little that is truly “objective” in the psychiatric exam.

The “subjective” part of SOAP refers to how the patient describes his issues, and is usually expressed as a verbatim quote. Pick and choose the quote that seems to best encapsulate your patient’s issues of the visit, e.g., “My day was horrible. My boss chewed me out and I know he’s about to fire me.”

The “objective” portion refers to the major psychiatric symptoms over recent weeks, including issues with sleep, appetite, energy, anxiety, suicidality, and the like. If you use numerical scales in your clinical work (see accompanying article for recommendations on how to use these), this is the place to insert them.

“Assessment” should include your DSM diagnosis--all five bitterly tedious axes. Insurance companies and disability reviewers will eventually want to see this information for most of our patients, and as much as we may hate to admit it, the multi-axial system forces us to think through issues to which we should pay attention. So get into the habit of writing down the actual DSM numbers for all your Axis 1 and Axis 2 diagnoses. Torture? You bet, but it is a good defense against intellectual (and therefore therapeutic) laziness. Similarly, Axis 3 forces us to remind ourselves of our patient’s medical issues at each visit, ensuring that we scrutinize our meds for possible interactions with other medications.
TCR’s Humble SOAP Revision:
“SOAP, SIR”

S: Subjective
O: Objective
A: Assessment
P: Plan
S: Side Effects
I: Instructions
R: Risks/Benefits

What about documentation of Axis 4 (“psychosocial stressors”) and Axis 5 (“global assessment of functioning”)? For Axis 4, simply writing “mild,” “moderate,” or “severe” is so vague as to be useless, but briefly noting the specific stressors can be a useful check on your patient’s progress from visit to visit.

With regard to GAF, I once considered the assignment of a number to describe a patient’s life functioning to be so reductionistic that I rebelled, randomly oscillating between 65 and 75 as the mood suited. A spate of coverage denials from insurance companies ensued – be advised that GAFs of 75 and greater may indicate too much health to qualify your patient for your care. Chastened, I still randomly oscillate, but now between 60 (“moderately poor functioning”) and 70 (“mildly poor functioning”). Of course, those of you involved in inpatient care will often be dealing with GAFs well below 50.

“P” is for “Plan” and there’s not much to add, other than to say that, medico-legally, adding a one-liner revealing the thinking that goes into your plan is a good idea. So it’s not just “Add lithium,” but “Add lithium in order to augment response to antidepressant.” In this example, if the lithium causes toxicity, you have a documented rationale for having used the medication in a patient without bipolar disorder. And so on for innumerable other possible scenarios.

Thus, the trusty SOAP mnemonic is pretty useful, but it does leave out a few important items that deserve documentation: medication instructions, side effects and risks vs. benefits of treatment. Some clinicians resort of an alphabet soup to save their writer’s hand--“I, S/E, R/B”, indicating that all three were addressed during the visit. This may be fine in general, but you may need to be more prolific in some instances. The prescription of MAOIs comes to mind, when you should write out what you discussed: “Went over contraindicated foods and meds, gave handout, discussed potential symptoms of hypertension, and R/B of MAOIs.”

A good way to remember to cover these is to add “SIR” to the SOAP mnemonic, as outlined in the box in the middle of this article. This will ensure that your progress notes are squeaky clean!

TCR VERDICT: Let’s make it “SOAP, SIR.”
General Psychiatry
    Carlat 150x150
    Daniel Carlat, MD

    Medication Fact Book for Psychiatric Practice, Seventh Edition (2024)

    More from this author
    www.thecarlatreport.com
    Issue Date: July 1, 2005
    SUBSCRIBE NOW
    Table Of Contents
    Talking Back to Managed Care
    Dr. Rebecca Brendel on HIPAA and Psychiatric Practice
    HIPAA Compliance for Psychiatrists: A One-Stop Shop
    Using Psychiatric Rating Scales in Clinical Practice
    The Humble Progress Note
    DOWNLOAD NOW
    Featured Book
    • MFB7e_Print_App_Access.png

      Medication Fact Book for Psychiatric Practice, Seventh Edition (2024) - Regular Bound Book

      The updated 2024 reference guide covering the most commonly prescribed medications in psychiatry.
      READ MORE
    Featured Video
    • KarXT (Cobenfy)_ The Breakthrough Antipsychotic That Could Change Everything.jpg
      General Psychiatry

      KarXT (Cobenfy): The Breakthrough Antipsychotic That Could Change Everything

      Read More
    Featured Podcast
    • shutterstock_2622607431.jpg
      General Psychiatry

      Should You Test MTHFR?

      MTHFR is a...
      Listen now
    Recommended
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png

    About

    • About Us
    • CME Center
    • FAQ
    • Contact Us

    Shop Online

    • Newsletters
    • Multimedia Subscriptions
    • Books
    • eBooks
    • ABPN Self-Assessment Courses

    Newsletters

    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
    • The Carlat Psychotherapy Report

    Contact

    carlat@thecarlatreport.com

    866-348-9279

    PO Box 626, Newburyport MA 01950

    Follow Us

    Please see our Terms and Conditions, Privacy Policy, Subscription Agreement, Use of Cookies, and Hardware/Software Requirements to view our website.

    © 2025 Carlat Publishing, LLC and Affiliates, All Rights Reserved.