SOAP Note on Major Depressive Disorder

Course: NURS-FPX4030: Health Assessment and Promotion in Nursing Practice

Assignment: Assessment 3 – Focused SOAP Note

Word Count: 4–6 pages (excluding title page and references)

Format: APA 7th Edition

Submission: Week 6, Day 7, 11:59 PM (CST)

Assignment Context

SOAP notes are the standard documentation format for healthcare providers. The acronym stands for Subjective, Objective, Assessment, and Plan. This structured approach ensures that clinical information is recorded clearly, consistently, and legally. Nurse practitioners in mental health settings use SOAP notes to document patient encounters in psychiatric clinics, inpatient units, and telehealth sessions. The format originated in the 1960s at the University of Vermont and has since become ubiquitous across medical and nursing education. The Joint Commission recognizes properly documented SOAP notes as part of the patient medical record and expects documentation to meet legal and professional standards. Healthcare providers must write notes that communicate clinical reasoning, support continuity of care, and protect both patients and practitioners in legal contexts.

Learners in NURS-FPX4030 complete this assessment to demonstrate competence in psychiatric documentation. The case of Jane Doe presents a 35-year-old woman with symptoms consistent with Major Depressive Disorder following a divorce. Students must evaluate the case information, organize it into the SOAP framework, produce a differential diagnosis list, and formulate a comprehensive treatment plan. A minimum of three peer-reviewed references published between 2018 and 2026 must support clinical decisions. The assignment assesses whether students can differentiate between subjective and objective data, apply diagnostic criteria, and justify clinical reasoning with evidence. Faculty will evaluate SOAP notes using a rubric that measures accuracy, organization, completeness, and scholarly writing.

Task Description

Write a SOAP note for the patient in the provided case study. Your note must follow the SOAP structure exactly: Subjective, Objective, Assessment, and Plan. Each section must contain the specific information required. Do not omit any section. Do not combine sections. Use the headings exactly as written below.

Section 1: Subjective Data

Document information the patient or family member reports. This section captures symptoms, history, and patient experience in the patient’s own words where possible. Include:

• Patient demographics (age, sex, marital status, occupation, living situation)
• Chief Complaint (CC): the reason for the visit in the patient’s words
• History of Present Illness (HPI): onset, duration, severity, precipitating factors, associated symptoms, and impact on daily functioning
• Past Medical History (PMHx): any previous medical conditions
• Current Medications: all prescribed, over-the-counter, and herbal supplements
• Allergies: drug, food, and environmental allergies
• Family History (Fam Hx): relevant psychiatric and medical conditions in first-degree relatives
• Social History (Soc Hx): substance use, living situation, employment, support systems
• Review of Systems (ROS): relevant positives and negatives across systems

Section 2: Objective Data

Document observable, measurable, and verifiable findings. This section contains data you collect through examination, observation, and diagnostic testing. Include:

• Vital signs: blood pressure, pulse, respiratory rate, temperature
• Physical exam findings: general appearance, behavior, grooming, eye contact, psychomotor activity
• Mental Status Examination (MSE): appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment
• Diagnostic study results: validated screening tool scores such as the PHQ-9
• Laboratory findings if available

Objective data must not include subjective interpretations. Record only what you observe, measure, or verify through standardized tools.

Section 3: Assessment

Provide your clinical formulation. This section synthesizes subjective and objective data into a diagnostic impression. Include:

• Primary diagnosis with ICD-10 code and justification from subjective and objective findings
• Differential diagnoses (at least three) with brief rationales explaining why each was considered and ruled in or ruled out
• Analysis of psychosocial and biological contributors to the current presentation
• Reference to DSM-5 diagnostic criteria to support the primary diagnosis

Do not simply list diagnoses. Explain the clinical reasoning behind each diagnostic decision. Support your assessment with citations from peer-reviewed literature.

Section 4: Plan

Formulate a comprehensive, evidence-based treatment plan. The plan must address the primary diagnosis and include:

• Diagnostic testing: any further assessments or laboratory tests needed
• Pharmacologic interventions: medication name, starting dose, titration plan, and rationale
• Non-pharmacologic interventions: psychotherapy referrals, lifestyle modifications, behavioral activation
• Referrals: psychiatry, counseling, social work, or other specialists
• Patient education: topics to cover with the patient including medication adherence, side effects, and safety planning
• Follow-up: specific timeline and parameters for reassessment

Use at least three peer-reviewed sources published between 2018 and 2026 to support the plan. Cite all sources in APA 7th edition format.

Requirements

• Write 4–6 pages, excluding the title page and reference list
• Use APA 7th edition formatting for the title page, headings, in-text citations, and references
• Include a minimum of three peer-reviewed references published between 2018 and 2026
• Use double spacing, 12-point Times New Roman font, and 1-inch margins
• Submit the note as a Word document through the course submission portal
• Include page numbers in the upper right corner
• Use headings exactly as specified: Subjective, Objective, Assessment, Plan

Grading Rubric

Criterion	Exemplary (90–100%)	Proficient (80–89%)	Developing (70–79%)	Unsatisfactory (0–69%)
Subjective Data (25 points)	All required components present; data accurate, organized, and comprehensive; patient’s voice preserved where appropriate	Most components present; minor omissions; data generally accurate and organized	Several components missing or inaccurate; organization unclear	Major components missing; data inaccurate or disorganized
Objective Data (25 points)	All required components present; MSE complete; diagnostic data accurately reported; clear distinction between subjective and objective	Most components present; MSE mostly complete; minor confusion between subjective and objective data	Several components missing; MSE incomplete; significant confusion between subjective and objective	Major components missing; no MSE; objective section contains subjective data
Assessment (25 points)	Primary diagnosis accurate with ICD-10 code; three or more differentials with sound rationales; clinical reasoning clear and evidence-based; DSM-5 criteria applied correctly	Primary diagnosis accurate; differentials present with adequate rationales; reasoning mostly clear; some evidence support	Primary diagnosis questionable; fewer than three differentials or weak rationales; reasoning unclear; limited evidence	Diagnosis incorrect or missing; no differentials; no clinical reasoning; no evidence support
Plan (25 points)	Comprehensive plan covering all required elements; interventions evidence-based and specific; follow-up timeline clear; patient education detailed	Plan covers most elements; interventions generally evidence-based; follow-up included; education adequate	Plan missing several elements; interventions vague; follow-up unclear; education minimal	Plan missing major elements; interventions inappropriate or absent; no follow-up
Scholarly Writing and APA (20 points)	No grammar, spelling, or punctuation errors; APA formatting flawless; references current and peer-reviewed	Minor writing errors; APA mostly correct; references appropriate	Multiple writing errors; APA formatting inconsistent; references weak	Major writing errors impair readability; APA absent; no peer-reviewed references

Total: 120 points

Sample Answer Excerpts

Clinical Reasoning in the Assessment Section

The assessment section of a SOAP note requires more than listing diagnoses. It demands a synthesis of subjective and objective data that demonstrates clinical reasoning. For Jane Doe, the PHQ-9 score of 18 indicates moderate-to-severe depression, which meets the threshold for active treatment. The DSM-5 criteria for Major Depressive Disorder require five or more symptoms present for at least two weeks, with at least one symptom being depressed mood or anhedonia. Jane reports both core symptoms alongside sleep disturbance, fatigue, feelings of worthlessness, and concentration difficulties. The differential diagnosis list should include Persistent Depressive Disorder, which requires a two-year duration and is ruled out because Jane’s symptoms began six months ago. Adjustment Disorder with Depressed Mood should also be considered because a psychosocial stressor (divorce) preceded symptom onset, but the severity and duration of symptoms exceed the threshold for Adjustment Disorder. Bipolar II Disorder must be ruled out by confirming the absence of hypomanic episodes, which Jane denies. A 2023 study by Bains and Abdijadid published in StatPearls confirms that MDD diagnosis depends on excluding manic or hypomanic episodes and ensuring symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The clinical reasoning should explicitly state why each differential was considered and why it was ruled in or out.

Pharmacologic Decision-Making in the Plan Section

Selecting an antidepressant for Major Depressive Disorder requires consideration of efficacy, side effect profile, patient preference, and cost. Sertraline at 50 mg daily represents a reasonable first-line choice for Jane. The medication belongs to the SSRI class, which the American Psychiatric Association recommends as first-line pharmacotherapy for MDD. Sertraline has a favorable side effect profile compared to older antidepressants and is generally well tolerated. Titration can occur after two to four weeks if the patient shows partial response without intolerable side effects. The plan should specify that sertraline may take four to six weeks to reach full therapeutic effect, and patients should not discontinue abruptly because of discontinuation syndrome risk. Non-pharmacologic interventions carry equal weight. Cognitive Behavioral Therapy has the strongest evidence base for MDD and should be initiated concurrently with pharmacotherapy. A 2022 meta-analysis by Cuijpers and colleagues in World Psychiatry found that combining pharmacotherapy and psychotherapy produces superior outcomes compared to either treatment alone. The plan must also address lifestyle modifications including aerobic exercise, sleep hygiene, and social engagement. Patient education should cover medication adherence, expected timeline for improvement, potential side effects, and warning signs that require immediate clinical contact.

Mental Status Examination Documentation

The Mental Status Examination anchors the Objective section of a psychiatric SOAP note. The MSE covers appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. For Jane Doe, the MSE should document that she appears tired with flat affect and psychomotor retardation. Speech is normal in rate and volume. Mood is described as depressed. Affect is flat and congruent with mood. Thought process is linear and goal-directed. Thought content reveals no suicidal ideation, homicidal ideation, or delusional content. Perception reveals no hallucinations. Cognition appears intact based on orientation and attention. Insight is fair; judgment is adequate. Each MSE component must be documented separately. Grouping them together or omitting components creates an incomplete record. The MSE provides objective evidence that supports the diagnosis and treatment plan. A 2019 article by O’Donnell and colleagues in the International Journal of Environmental Research and Public Health emphasizes that thorough documentation of mental status findings distinguishes Major Depressive Disorder from Adjustment Disorder and other mood disturbances.

DSM-5 Diagnostic Criteria Application

Major Depressive Disorder requires the presence of five or more of nine specific symptoms during the same two-week period. At least one symptom must be either depressed mood or loss of interest or pleasure. Jane reports depressed mood, anhedonia, insomnia, fatigue, feelings of worthlessness, and concentration difficulties. That totals six symptoms, which exceeds the diagnostic threshold. The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Jane’s report of poor concentration and indecisiveness suggests occupational impairment as an accountant. The symptoms must not be attributable to a substance or another medical condition. Jane takes no medications and has no relevant medical history. The symptoms must not be better explained by a psychotic disorder. Jane denies psychotic symptoms. A 2023 review by Patel and Rose in StatPearls confirms that applying DSM-5 criteria systematically reduces diagnostic error and ensures that treatment planning aligns with evidence-based protocols. Students should quote specific DSM-5 criteria in the Assessment section rather than making general statements about depression.

References

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2022). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 21(1), 73–82. https://doi.org/10.1002/wps.20935

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Patel, R. K., & Rose, G. M. (2023). Persistent depressive disorder (dysthymia). In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541052/

Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report

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Week 7 Assignment: Pharmacologic Management of Major Depressive Disorder

Course: NURS-FPX4030: Health Assessment and Promotion in Nursing Practice

Assessment: Assessment 4 – Medication Management Discussion

For this assessment, analyze the pharmacologic treatment options for the patient in the Week 6 SOAP note case study. Compare sertraline, escitalopram, and venlafaxine across efficacy, side effect profile, drug interactions, and cost. Recommend one medication and justify your selection with at least three peer-reviewed sources published between 2018 and 2026. Address monitoring parameters, titration schedule, and patient education points. Post your initial response of 500–700 words by Day 4 and respond substantively to at least two peers by Day 7.

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Sample Focused SOAP Note: Major Depressive Disorder

Patient: Jane Doe
Date: October 13, 2026
Provider: [Student NP Name], APRN
Setting: Outpatient psychiatric clinic

Subjective

Jane Doe is a 35-year-old divorced female accountant who lives alone in an apartment. She presents for evaluation of persistent sadness and loss of interest, stating, “I just feel empty all the time, and nothing matters anymore.” The chief complaint began approximately six months ago after her divorce and has gradually worsened. She reports depressed mood most of the day, nearly every day, with anhedonia, insomnia, fatigue, poor concentration, and feelings of worthlessness. She describes difficulty completing routine work tasks, frequent indecisiveness, and withdrawal from friends and family. She denies suicidal ideation, homicidal ideation, hallucinations, delusions, manic or hypomanic episodes, and substance use. She has no significant past medical history, takes no prescribed medications, over-the-counter products, or herbal supplements, and reports no known drug, food, or environmental allergies. Her father has a history of depression, while her mother has hypertension. She denies tobacco, alcohol, and recreational drug use. She lives alone, remains employed, and reports limited social support since the divorce. Relevant review of systems is positive for depressed mood, sleep disturbance, fatigue, and impaired concentration; she denies fever, chills, chest pain, shortness of breath, weight change, gastrointestinal symptoms, neurological deficits, or trauma.

Objective

Vital signs: Blood pressure 118/76 mmHg; pulse 74 beats per minute; respiratory rate 16 breaths per minute; temperature 98.4°F (36.9°C); oxygen saturation 99% on room air.

Physical examination: The patient appears tired and appropriately groomed. She maintains limited eye contact and demonstrates psychomotor retardation. No acute distress, abnormal movements, or focal neurological deficits are observed.

Mental Status Examination (MSE):

• Appearance: Age-appropriate, neatly dressed, tired appearance.

• Behavior: Cooperative, slowed motor activity, reduced eye contact.

• Speech: Normal rate, rhythm, volume, and articulation.

• Mood: “Depressed.”

• Affect: Flat and congruent with reported mood.

• Thought process: Linear and goal-directed.

• Thought content: No suicidal or homicidal ideation; no delusions.

• Perception: No auditory or visual hallucinations.

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• Cognition: Alert and oriented to person, place, time, and situation; attention and concentration appear mildly impaired.

• Insight: Fair; recognizes depressive symptoms.

• Judgment: Adequate; agrees to treatment and safety planning.

Diagnostic studies: PHQ-9 score is 18, indicating moderately severe depressive symptoms. The PHQ-9 uses thresholds of 5, 10, 15, and 20 for mild, moderate, moderately severe, and severe symptoms, respectively, and its nine items correspond closely to DSM depressive-disorder criteria (Kroenke, 2021). No laboratory results are currently available.

Assessment

Primary diagnosis: Major Depressive Disorder, single episode, moderate; ICD-10 code F32.1. Jane meets DSM-5 criteria for a major depressive episode because she reports six symptoms during the same period: depressed mood, anhedonia, insomnia, fatigue, worthlessness, and impaired concentration. At least one core symptom is present, symptoms have lasted more than two weeks, and they cause clinically significant occupational and social impairment (American Psychiatric Association, 2022). The presentation is not attributable to a substance, medical condition, or psychotic disorder, and she denies any lifetime manic or hypomanic episode. Bains and Abdijadid (2023) note that MDD is characterized by persistent low mood, anhedonia, guilt or worthlessness, fatigue, poor concentration, sleep disturbance, and possible suicidal thoughts, with diagnosis requiring exclusion of bipolar disorder and other explanations.

Differential diagnoses:

• Persistent Depressive Disorder (F34.1): Considered because of chronic low mood and functional impairment. It is ruled out because Jane’s symptoms began six months ago, whereas persistent depressive disorder requires depressed mood for at least two years (Patel & Rose, 2023).

• Adjustment Disorder with Depressed Mood (F43.21): Considered because divorce preceded symptom onset. It is ruled out because her symptom count, PHQ-9 severity, and degree of impairment exceed the expected response to an identifiable stressor (O’Donnell et al., 2019).

• Bipolar II Disorder (F31.81): Considered because depressive episodes may occur in bipolar spectrum illness. It is ruled out because Jane denies past elevated or irritable mood, decreased need for sleep, increased energy, impulsivity, or other hypomanic symptoms.

• Substance/Medication-Induced Depressive Disorder: Considered because substances can produce depressive symptoms. It is ruled out because Jane denies alcohol, tobacco, recreational drug use, and medication or supplement use.

Contributing factors: The divorce represents a major psychosocial stressor and has reduced her support system. Her isolation, work impairment, and sleep disruption likely reinforce depressive symptoms through reduced reinforcement from pleasurable activities. Biological vulnerability may also contribute, given her father’s history of depression. The clinical picture therefore reflects an interaction between stress, social disconnection, and possible familial predisposition.

Plan

Diagnostic testing: Obtain CBC, CMP, TSH, vitamin B12, vitamin D, and urine drug screen to exclude anemia, thyroid disease, metabolic disturbance, nutritional deficiency, and substance-related causes. Repeat the PHQ-9 at each follow-up visit to monitor symptom response. Assess suicide risk using the Columbia Suicide Severity Rating Scale at today’s visit and at subsequent appointments.

Pharmacologic intervention: Initiate sertraline 50 mg orally once daily in the morning. This starting dose is consistent with recommended adult dosing for MDD; the maintenance range is 50 to 200 mg daily, with dose adjustments made no more frequently than weekly based on response and tolerability (Sheffler et al., 2023). Reassess in two to four weeks. If partial response occurs without intolerable adverse effects, increase to 100 mg daily; do not titrate further without clinical reassessment. Educate Jane that antidepressant benefit may take four to six weeks, that she should not stop the medication abruptly, and that she should report worsening mood, agitation, or suicidal thoughts immediately.

Non-pharmacologic intervention: Refer Jane to cognitive behavioral therapy (CBT), with weekly sessions for at least 12 weeks. CBT addresses depressive thought patterns and supports behavioral activation through scheduled, achievable activities. Combined psychotherapy and pharmacotherapy produces better short-term response than either treatment alone for moderate depression (Cuijpers et al., 2020). Encourage 30 minutes of moderate aerobic activity most days, consistent sleep and wake times, reduced evening screen use, regular meals, and gradual reconnection with supportive contacts.

Referrals: Refer to a licensed mental health counselor for CBT. Refer to social work for assistance with post-divorce resources, insurance verification, and community support. Refer to psychiatry if symptoms worsen, if suicidal ideation emerges, or if there is an inadequate response after adequate sertraline trial and psychotherapy engagement.

Patient education: Explain the diagnosis, the role of serotonin reuptake inhibition, expected treatment timeline, and common sertraline effects, including nausea, headache, insomnia, sexual dysfunction, and gastrointestinal upset. Review warning signs requiring urgent care: suicidal thoughts, self-harm intent, severe agitation, or inability to function. Provide the 988 Suicide and Crisis Lifeline number and develop a written safety plan that identifies warning signs, coping strategies, supportive contacts, and emergency services.

Follow-up: Schedule follow-up in two weeks to assess tolerability, adherence, sleep, functional status, and suicide risk. Repeat PHQ-9 at four weeks and reassess treatment response. If symptoms improve, continue current treatment and follow up monthly for at least six months after remission. If no meaningful improvement occurs after six to eight weeks at an effective dose, reassess diagnosis, adherence, psychosocial stressors, and the need for psychiatric consultation.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Cuijpers, P., Noma, H., Karyotaki, E., Vinkers, C. H., Cipriani, A., & Furukawa, T. A. (2020). A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry, 19(1), 92–107. https://doi.org/10.1002/wps.20701

Kroenke, K. (2021). PHQ-9: Global uptake of a depression scale. World Psychiatry, 20(1), 135–136. https://doi.org/10.1002/wps.20821

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Patel, R. K., & Rose, G. M. (2023). Persistent depressive disorder (dysthymia). In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541052/

Sheffler, Z. M., Patel, P., & Abdijadid, S. (2023). Sertraline. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547689/