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Session input Example session

Client discussed increased anxiety related to work and difficulty sleeping over the past week. Client reported using breathing exercises twice and stated they were helpful during periods of heightened stress.

Session captured 01:24
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SOAP Note Generated and ready to review
Generated in 0:42
DICTATION Jordan M. · Session 12
02:14
Listening

“...she’s sleeping closer to seven hours, and caught herself
catastrophizing about the review...”

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FORMAT

SOAP note

Oct 1 · 50 min
SUBJECTIVE

Reduced work stress; sleep improved to 6–7 hrs.

OBJECTIVE

Affect congruent, mildly anxious discussing review.

ASSESSMENT

Progressing toward Goal 1; no safety concerns.

PLAN

Weekly CBT. Two thought records before review.

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SOAP · Assessment

Jordan M.

Client seemed to be doing a lot better this week and talked about how work has been less stressful and she's been sleeping better and also using the breathing stuff we practiced before meetings.

Make more concise
↵
SUGGESTED

Client reports reduced work stress and improved sleep. Uses diaphragmatic breathing before meetings to manage anticipatory anxiety.

Session Continuity

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PREVIOUS SESSION

September 3

✓
Primary focus Work-related anxiety
Intervention Breathing exercises
Follow up Sleep quality
Session context carried forward Relevant details are ready for your next note
CURRENT SESSION

September 10

In progress
CONTEXT FROM LAST SESSION

Client previously reported increased work-related anxiety and difficulty sleeping.

TODAY

Client reports improved sleep and continued use of breathing exercises during periods of heightened stress.

Relevant follow-up detected Sleep quality and coping strategy use
JM
Josh M. 6 sessions
JM
TREATMENT PLAN Jordan M.
Draft
PRESENTING PROBLEM

Work-related anxiety with sleep disruption (F41.1).

Goal 1 Reduce work-related anxiety
1a

Coping skill before 4 of 5 weekly meetings

1b

Self-rated anxiety ≤ 4/10 within 8 weeks

INTERVENTIONS
Cognitive restructuring Thought records
Treatment Plans

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