Social Work Soap Note

SOAP Note

This SOAP note represents a structured method for documenting patient information, assessments, and any subsequent diagnosis or treatment plans. Prepared by Herman W. Santana from Cloud Crest Consulting, it reflects the best practices in social work and clinical consultation.

Subjective	Objective	Assessment	Plan
Mr. Martinez, a 33 years old male, 5'9" and 165 lbs, went to our clinic on April 12, 2050 for consultation. He stated experiencing restlessness, insomnia, concentration issues, and occasional panic attacks.	Physical examination: General appearance looks fatigued, vital signs stable. Mental status examination: Mildly agitated, speech normal in rate, volume, and prosody. Thought process logical and goal directed. Evidence of moderate anxiety. No self-harm ideation reported.	Moderate generalized anxiety disorder (GAD). No evidence of major mental illness.	Cognitive-behavioral therapy (CBT) to manage anxiety triggers. Recommend regular physical exercise and good sleep hygiene. SSRIs (Selective serotonin reuptake inhibitors) if symptoms persist and affect the quality of life. Regular follow-up appointments for monitoring progress.

This note is intended to be a part of Mr. Martinez's overall social work and health and wellness strategy. All recommendations and decisions were made in line with the best practices, peer-reviewed research, and expertise provided by the Cloud Crest Consulting Team, headed by Mr. Herman W. Santana.