Work Stress SOAP Note Example for Therapists

With work stress, the note needs to separate what depends on the person from what depends on their working conditions, and to record distress without turning terms such as “burnout” into a diagnosis. If the person is on sick leave, it helps to make clear who manages it and what role psychotherapy plays.

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

Fictional work stress SOAP note example

Context: Fourth session, acceptance and commitment therapy (ACT). Presenting concern: exhaustion, irritability and difficulty concentrating associated with work overload. The person has been on sick leave for three weeks; the sick leave is managed by her GP.

Subjective: The person reports that she has been sleeping better since going on sick leave, about seven hours, but that on Sunday night, when thinking about going back, her “stomach shut” and she could not sleep. She feels guilty about being on sick leave and thinks her colleagues will see her as “weak”. She has taken up swimming again two days this week. She identifies what matters most to her as “doing my job well without giving up having a life”. She is worried about the conversation with her manager about returning to work. She reports that her team's workload remains the same.

Objective: Posture and pace of speech more relaxed than in the first session. Becomes tearful when talking about guilt. Takes part in a defusion exercise (“I'm having the thought that I'm weak”) and reports that the thought “loses strength” when phrased that way.

Assessment: Improved rest and recovery of self-care activities during sick leave. Fusion with thoughts of inadequacy and guilt are now the main obstacle, together with anticipation of the return to work. According to her account, the working conditions that precipitated the distress have not changed, so the return requires preparing concrete boundaries. The values identified offer a direction for that work.

Plan: Practise defusion with thoughts of “being weak” when they arise, noting the situation. Write down three concrete boundaries she wants to raise with her manager and rehearse them at the next session. Keep up swimming. If the person requests it, consider a psychological report on the process for her GP, agreeing its content with her.

Why it is written this way

The note does not use “burnout” as a diagnosis. In ICD-11, burnout is described as an occupational phenomenon and not as an illness, so it is more useful to describe distress and functioning.

Sick leave is attributed to whoever manages it. Psychotherapy can provide a report when requested, but in Spain sick leave for a non-work-related illness (incapacidad temporal por contingencia común) is issued and monitored by the public health service doctor.

Thoughts are recorded as thoughts (“she thinks they will see her as weak”) and not as facts about the work environment.

The assessment distinguishes what depends on the person from what depends on working conditions, without attributing all the distress to one side. That distinction guides the plan: working on the relationship with thoughts and, at the same time, preparing concrete boundaries.

The same session as a progress note

Fourth ACT session. On sick leave for three weeks, managed by her GP. Improved sleep and return to swimming. Guilt about the sick leave and thoughts of being “weak”, with a good response to defusion in session. Anticipatory anxiety about returning to work; according to her account, working conditions have not changed. Value identified: doing her job well without giving up her personal life. Agreed to prepare three boundaries to discuss with her manager.

Questions to use during review

• Does the note describe distress and functioning without using “burnout” as a diagnosis?
• Is it clear who manages the sick leave and what role psychotherapy plays?
• Are the person's thoughts recorded as thoughts and not as facts?
• Are personal factors distinguished from working conditions?
• If a report is being prepared, does the note record that the person requested it and agreed its content?

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

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