Grief SOAP Note Example for Therapists

In grief work, the note needs to capture pain without turning it into a symptom by default. What makes it possible to assess the course of grief is how that pain coexists with everyday functioning, relationships and moments of reorganisation.

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

Fictional grief SOAP note example

Context: Fifth session, integrative approach. Grief following the death of her mother five months ago, after a long illness.

Subjective: The person reports an uneven week: on some days she works normally and on others she cries when she comes across her mother's belongings. She is worried about her mother's birthday on 25 October, the first without her. She has started meeting a friend again and describes it as “a breather”. She explains that she sometimes feels guilty for not having been at the hospital on the night her mother died. She sleeps about six hours, with awakenings during which she thinks about her. When asked directly, she denies thoughts of death or wishes to be reunited with her mother.

Objective: Arrives on time. Cries when talking about the last night at the hospital and composes herself without help. Affect is congruent with content, and she smiles when recalling shared anecdotes. She brings the photographs she had chosen for the session, as agreed.

Assessment: The process shows an expected oscillation between loss-focused moments and moments of reorganising everyday life. She maintains her work functioning and is beginning to recover social contact. Guilt about not being present at the death is the most emotionally charged theme. The birthday may intensify distress. There are no current indications of prolonged grief; moreover, at five months the minimum time required by the criteria has not been met.

Plan: Plan with the person how she wants to spend the day of the birthday (ritual, company, activity). Write a letter to her mother about the night at the hospital, to work on at the next session if she wishes. Maintain weekly social contact. Review sleep and guilt at the next session.

Why it is written this way

The note does not turn crying or sadness into symptoms. It describes distress alongside functioning, which is what makes it possible to assess the course of grief.

It captures both poles of the process: what hurts and what is gradually being recovered. A note that records only distress gives an incomplete picture and can lead to over-intervention.

The significant date is recorded as a specific date, because “in two weeks” loses its meaning when the note is reread later, and it appears again in the plan. That way, whoever picks up the case knows it needs to be prepared for.

The assessment is cautious about prolonged grief. The criteria for prolonged grief disorder require a minimum time since the loss, six months in ICD-11 and twelve months for adults in DSM-5-TR, so the note does not get ahead of itself. The question about thoughts of death is recorded with what was asked and what the person answered, rather than a generic “no risk”.

The same session as a progress note

Fifth session. Grief following the death of her mother five months ago. Week oscillating between functional days and moments of crying. Resumes contact with a friend. Guilt about not being present at the death, the central theme of the session. Sleeps about six hours, with awakenings. Denies thoughts of death on direct enquiry. The mother's first birthday since her death (25 October) is planned for and a letter is proposed for the next session.

Questions to use during review

• Does the note describe distress without automatically presenting it as pathology?
• Does it also record functioning and the resources that are maintained or recovered?
• Are significant dates that need preparing for recorded?
• Is the assessment of the course of grief proportionate to the time that has passed?
• Is the exploration of thoughts of death recorded with what was asked and the answer?

See the SOAP notes guide and the guide to mental health progress notes. You can also compare this case with the depression example or the trauma example.

Clara prepares an editable draft from the session and keeps context between sessions, such as dates that need preparing for. The clinician reviews the language and the assessment before adding it to the record. See AI clinical notes with Clara.