Insomnia SOAP Note Example (CBT-I)

In cognitive behavioural therapy for insomnia (CBT-I), the decisions made in each session depend on the sleep diary data. The note needs to record those figures in a comparable way, explain why the sleep window is extended or maintained, and document the safety precautions.

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 insomnia SOAP note example

Context: Third CBT-I session. Presenting concern: difficulty staying asleep for the past year. The initial assessment found no other medical or psychological conditions relevant to the plan.

Subjective: Brings the sleep diary for the week. He reports that he has found it hard to keep to the agreed schedule, 00:30 to 6:30, especially getting up at the same time at the weekend. He got out of bed when he could not sleep, as agreed, on four of the seven nights. He notices more tiredness during the day, and on Wednesday he felt drowsy while driving to work. He is worried that he will “never sleep well again”.

Objective: The diary shows a mean time in bed of 6 hours 15 minutes (15 minutes more than the prescribed 6-hour window, because of the weekends), compared with 8 hours 30 minutes at baseline, with an estimated mean sleep time of 5 hours 30 minutes. Sleep efficiency rises from 65% to 88%. He takes part in reviewing the diary and calculates efficiency with help.

Assessment: Initial response to sleep restriction: sleep efficiency is above 85% with a sleep time similar to baseline. The increase in daytime sleepiness is expected at this stage, but the episode while driving calls for safety measures. Worries about sleep maintain arousal at bedtime and will be the focus of the cognitive component.

Plan: Extend the sleep window by 15 minutes, to 00:15 to 6:30, because efficiency is above 85%, the criterion of the protocol being used. It is agreed that he will not drive if he feels drowsy, will find another way to get to work for as long as this lasts and will avoid long car journeys during this phase. Maintain stimulus control and the fixed wake-up time, including at weekends. Begin working on beliefs about sleep at the next session.

Why it is written this way

Diary data are recorded as comparable figures. In CBT-I, extending or reducing the sleep window depends on them, so the note should make it possible to reconstruct why each decision was taken.

Sleep efficiency is calculated as sleep time divided by time in bed. In this case, 5 hours 30 minutes divided by 6 hours 15 minutes gives 88%. Recording both values avoids doubts when the case is reviewed.

Drowsiness while driving appears alongside the agreed measure. Sleep restriction increases daytime sleepiness, and documenting the warning is part of safe practice.

The context records that the initial assessment found no other relevant conditions. Sleep restriction (restricting time in bed) calls for caution in some situations, such as bipolar disorder, epilepsy or untreated sleep apnoea, and the note should show that this was taken into account.

The same session as a progress note

Third CBT-I session. Sleep diary: time in bed 6 h 15 min (8 h 30 min at baseline), estimated sleep 5 h 30 min, efficiency 88% (65% at baseline). Stimulus control applied on four of seven nights. Daytime sleepiness and one episode of drowsiness while driving: agreed not to drive when drowsy. Window extended to 00:15 to 6:30. Next session: beliefs about sleep.

Questions to use during review

• Are the diary data recorded in a way that can be compared with baseline?
• Is it clear why the sleep window is extended, maintained or reduced?
• Have daytime sleepiness and the safety warnings been recorded?
• Does the note show that situations in which sleep restriction is not advisable were considered?
• Does the plan specify the new schedule and what will be reviewed?

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 panic attack example.

Clara prepares an editable draft from the session. The clinician checks the figures, the decisions about the schedule and the warnings before adding it to the record. See AI clinical notes with Clara.