Mental Health Soap Note

SOAP Note

Prepared by: Maranda M. Ochs, Future Glow Dynamics

Date: January 5, 2050

This SOAP Note is a professionally structured report, designed for mental health professionals to evaluate and plan the treatment strategy for Ethan Wilson. The document delves into the Subjective and Objective observations, leading to an Assessment and eventually forming a conclusive Plan.

S	O	A	P
Subjective Patient: Ethan Wilson Age: 26 years Gender: Male Height: 5'9" Weight: 160 lbs	Objective Patient appears anxious and restless Reports difficulty in concentrating Experiencing sleep disturbances Expresses feeling of emptiness and hopelessness	Assessment Mental Health: The patient shows symptoms commonly associated with severe anxiety and depression. His inability to focus, distress, and statements about hopelessness are concerning.	Plan Commence Psychotherapy: Cognitive behavioural therapy (CBT) Pharmacological intervention: Antidepressants Follow-up consultation in two weeks Mental health maintenance strategies to be discussed in subsequent sessions

Subjective

Patient: Ethan Wilson
Age: 26 years
Gender: Male
Height: 5'9"
Weight: 160 lbs

Objective

Patient appears anxious and restless
Reports difficulty in concentrating
Experiencing sleep disturbances
Expresses feeling of emptiness and hopelessness

Assessment

Mental Health: The patient shows symptoms commonly associated with severe anxiety and depression. His inability to focus, distress, and statements about hopelessness are concerning.

Plan

Commence Psychotherapy: Cognitive behavioural therapy (CBT)
Pharmacological intervention: Antidepressants
Follow-up consultation in two weeks
Mental health maintenance strategies to be discussed in subsequent sessions