Alcohol Use SOAP Note Example for Therapists

When working on alcohol use, the note needs to quantify drinking with a clear unit, capture ambivalence in the person's own words and record the goal the person has chosen. It also needs to document the enquiry about withdrawal symptoms, because this determines the safety of any plan to cut down.

The example below is fictional and educational. It is not a diagnostic or medical assessment, and it does not replace professional judgement or applicable documentation requirements.

Fictional alcohol use SOAP note example

Context: Third session, motivational interviewing approach. Presenting concern: worry about his drinking after his doctor linked some blood test results to his alcohol use.

Subjective: The person reports drinking on four days this week, mainly beer and wine when he gets home from work. According to his own record, this came to about 24 standard drink units (UBE; one unit is 10 g of pure alcohol in Spain), compared with about 35 the previous week. He explains that drinking “switches him off” after tense days and that he does not see himself “as an alcoholic”. He is worried that his daughter told him he “always has a drink in his hand”. He wants to cut down, not stop completely, and rates his confidence in achieving this at 6 out of 10. When asked, he denies tremor, sweating or feeling unwell in the mornings, and any history of seizures or withdrawal when cutting down.

Objective: Participates openly and brings the drinking record for five of the seven days. Becomes defensive when the word “alcoholism” comes up and relaxes when the conversation returns to his own reasons for change. He puts forward two reasons of his own for cutting down: his health and his relationship with his daughter.

Assessment: The person is at a point of ambivalence, with reasons for change increasingly present and a clear function of drinking as a way of regulating stress. The reduction compared with the previous week is notable, although drinking remains above the low-risk limits set out by the Spanish Ministry of Health (20 g a day for men and 10 g for women; there is no risk-free level of drinking). Labels generate discord, so it is best to keep the focus on his own goals. He reports no withdrawal symptoms in today's enquiry.

Plan: Goal proposed by the person: no drinking from Monday to Thursday and a maximum of two UBE on days when he drinks. Replace the drink on getting home with a shower or a short walk, alternatives the person himself suggests for switching off. Continue the drinking record. Suggest to the person coordinating with his GP, with his consent, to find out whether the blood test results point to an abstinence goal. Review progress and difficulties at the next session.

Why it is written this way

Drinking is quantified in UBE and attributed to its source: the person's own record. In Spain, one UBE is equivalent to 10 grams of pure alcohol, and using this unit makes it possible to compare weeks and speak the same language as primary care.

The note captures ambivalence in the person's own words, including his reasons for change. In motivational interviewing, those reasons are the most useful information for the next session.

The goal is the one the person proposes, cutting down rather than stopping completely, and it is recorded as such. The note avoids labels such as “alcoholic” or “denial”, which add nothing to the work and can damage the therapeutic relationship if the person reads his record.

The question about withdrawal symptoms is recorded because, if they were present, cutting down or stopping drinking abruptly could require medical supervision.

The same session as a progress note

Third session. Recorded drinking of about 24 UBE this week over four days (35 the previous week), mainly on getting home. Main function: switching off from work stress. Ambivalence, with two reasons of his own for cutting down: health and his relationship with his daughter. Rejects the label of alcoholism. Denies withdrawal symptoms. Goal chosen by the person: no drinking from Monday to Thursday and a maximum of two UBE on days when he drinks. Coordination with primary care is suggested to find out whether the blood test results point to abstinence.

Questions to use during review

• Is drinking quantified with a clear unit and attributed to its source?
• Are the reasons for change recorded in the person's own words?
• Is the recorded goal the one agreed with the person and not an imposed one?
• Does the note record the enquiry about withdrawal symptoms and, if present, medical coordination?
• Does the note avoid labels that add nothing to care?

See the SOAP notes guide and the guide to mental health progress notes. You can also compare this case with the work stress example or the eating disorder example.

Clara prepares an editable draft from the session, in the language of each clinician's orientation. The therapist reviews the figures, the agreed goal and the withdrawal enquiry before adding it to the record. See AI clinical notes with Clara.