SOAP note example: depression
A depression note carries more than symptoms. It must show that risk was assessed and what was agreed if things get worse, in words that another clinician can act on. The invented notes here are illustrations of structure, not clinical guidance. They show a first presentation with a risk assessment and a follow-up visit, then what each SOAP section should hold.
Example: first presentation of low mood
S: 38-year-old woman, 6 weeks of low mood, loss of interest in things she used to enjoy, poor sleep with early waking, low energy and poor concentration at work. Appetite reduced, weight stable. Feels guilty about not coping. Triggered by relationship breakdown 3 months ago. No previous episodes. No history of elevated mood. Alcohol 2 to 3 glasses of wine a week, no drugs. Lives with her 10-year-old son. Supportive sister nearby. Still working. Risk: Has felt that life is not worth living on some days. No thoughts of ending her life, no plans, no intent, no preparations. No self-harm now or in the past. No access to stockpiled medicines. Protective factors: her son, her sister, her work. No concerns for the child's safety raised. O: Well kempt, good eye contact, speech normal in rate. Mood low, affect reactive. Thought content: no delusions. No perceptual disturbances. Insight good. PHQ-9: 14. GAD-7: 8. A: Moderate depressive episode, first episode. Suicide risk assessed as low at present, with passive thoughts only and strong protective factors; risk can change. P: 1. Talking therapy referral; she agrees. 2. Sertraline 50 mg once daily discussed; she chose to start. Early side effects and delayed benefit explained. 3. Safety plan agreed: contact the clinic, an out-of-hours service or emergency services if thoughts of self-harm or suicide appear. Crisis numbers given in writing. 4. Sleep and activity advice. 5. Review in 2 weeks, earlier if worse.
Invented patient. This example shows documentation structure only. Assessment and treatment decisions belong to the treating clinician and local protocols.
What belongs in each section of a depression note
Subjective covers the core symptoms and their duration, sleep, appetite, energy, concentration, guilt, the effect on work and relationships, triggers, past episodes, any history of elevated mood, alcohol and drug use, and support. The risk assessment deserves its own clearly labelled line or block: thoughts that life is not worth living, suicidal thoughts, plans, intent, preparations, past attempts or self-harm, access to means, protective factors, and risk to or from others, including dependants.
Objective is the mental state examination: appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition as observed, and insight. Questionnaire scores such as PHQ-9 and GAD-7 go here with the number.
The Assessment names severity and whether this is a single or recurrent episode, and states the risk level in words with the reasons. The Plan lists therapy, any medicine with dose and what was explained, the safety plan and crisis contacts given, who else is involved, and a specific review interval.
Example: two-week follow-up
S: Started sertraline 50 mg 2 weeks ago. Mild nausea first 5 days, now settled. Sleep slightly better, mood unchanged. Therapy assessment booked. Risk: no thoughts of suicide or self-harm since last visit, no plans or intent. Protective factors unchanged. O: Mood low, affect more reactive. PHQ-9: 12. A: Moderate depressive episode, early treatment, tolerating medicine. Risk remains low. P: Continue sertraline 50 mg. Safety plan reviewed and still in place. Review in 4 weeks.
Gaps that matter in depression notes
- No risk assessment written, or only "no SI" without plans, intent, history and protective factors.
- Risk not reassessed at follow-up after a medicine was started.
- Safety plan discussed but not written into the plan.
- History of elevated mood not asked before starting an antidepressant.
- Questionnaire mentioned without the score.
- Dependants and safeguarding not considered.
ICD-10 codes for depression
| Code | Meaning |
|---|---|
| F32.0 | Major depressive disorder, single episode, mild |
| F32.1 | Major depressive disorder, single episode, moderate |
| F32.2 | Major depressive disorder, single episode, severe without psychotic features |
| F33.1 | Major depressive disorder, recurrent, moderate |
| F32.A | Depression, unspecified (ICD-10-CM) |
| R45.851 | Suicidal ideations (ICD-10-CM) |
Wording above is ICD-10-CM; base ICD-10 titles the same codes as depressive episode and recurrent depressive disorder.
ClearPass in a mental health consultation
Depression visits are long conversations and hard to type during without losing eye contact. With the patient's agreement confirmed, Transcribe lets you listen, and ClearPass drafts the SOAP note afterwards with the history, the risk questions and answers, the mental state examination and the plan. Detailed mode keeps the full risk discussion; use it for these visits.
ClearPass does not assess risk. It writes what was said, and the risk line in the draft is only as complete as the questions you asked. The numbers check marks any score or dose not in the transcript. ICD-10 codes, patient instructions with crisis contacts, and a referral letter for therapy are each one click. Review everything before it enters the chart.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
How should a suicide risk assessment appear in a SOAP note?
As a labelled line or block in Subjective covering thoughts, plans, intent, preparations, past attempts, access to means and protective factors, with the risk judgement and its reasons in Assessment and the safety plan in Plan.
Should the PHQ-9 go in Subjective or Objective?
Most clinicians put the score in Objective as a measured result, and the patient's description of symptoms in Subjective.
Does ClearPass decide the level of risk?
No. It is a documentation aid and does not make clinical decisions. It drafts the note from what you and the patient said; you review and correct it.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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