How to Build Custom SOAP Note & SDOH Forms in OpenEMR for Mental Health Providers

OpenEMR is an advanced, open-source EHR system that allows deep customization to support specialized clinical workflows. In mental and behavioral health settings, providers often need more than the generic templates, for example, they may want structured sections for psychotherapy notes, psychiatric history, mood ratings, and so on. 

Likewise, tracking patients’ social context through a Social Determinants of Health screen is increasingly important for holistic care. OpenEMR 7.0 and later even includes a built-in “Social Screening” encounter form covering SDOH categories. In this guide, we’ll walk through creating custom forms in OpenEMR, specifically a custom SOAP note form for mental health and an SDOH screening form, using the Layout-Based Visit Form tools and related features.

What Are Custom SOAP Note Forms in OpenEMR?

OpenEMR is a cutting-edge, open-source EHR solution that can be extensively customized to meet unique clinical operations. In mental and behavioral health settings, providers frequently need more than simple templates, such as structured sections for mood ratings, psychotherapy notes, and psychiatric history. Custom SOAP note formats can be made in OpenEMR to satisfy these requirements.

These patient encounter templates are intended for mental health documentation and follow the Subjective-Objective-Assessment-Plan pattern. When appropriate, clinicians may include fields like chief complaints, symptom checklists, and standardized scores.

Essentially, a Custom SOAP Note Form in OpenEMR is an LBV form that captures all the relevant SOAP data points for a mental health visit.

Understanding OpenEMR Custom Forms and Layout-Based Visit Forms

OpenEMR uses its Layout-Based Visit form engine for custom clinical forms. An LBV form is essentially a template of labeled data fields that the user can define. 

To create a new form, you first register it in OpenEMR’s form list, then design its layout by adding field “groups” and data elements. As the OpenEMR manual notes, LBV forms are “the basic type of custom data collection form”. The community contributes many example forms (including specialty-specific ones) for reuse. 

• In practice, to build any custom form, you go to Administration → Lists and select Layout-Based Visit Forms. 
• There, you add a new row with a unique Form ID and name. 
• OpenEMR will prefix the ID with “LBF” or “LBV”; avoid spaces or special characters. 
• For example, you might enter ID MHSOAP and name “MH SOAP Note” and click Save. 

This registers the form so it appears in the list of available encounter templates.

Step 1: Create a Custom SOAP Note Form in OpenEMR

Once you’ve added your new form to the list, the next step is to define its fields. 

• Go to Administration → Layouts. 
• In the “Edit Layout” section, use the dropdown to select the form you just named. 
• You can now build the form structure by clicking Add Group. 
• Each “Group” can represent a section of the note (for example, Initial Assessment, Ongoing Therapy, or Follow-Up) and can contain multiple fields. 
• Upon clicking Add Group, OpenEMR automatically creates the first field entry for that group.
• For each field, you must set parameters such as Order, ID, Label, Data Type, and Label/Data Columns. 

For example, in a mental health SOAP form, you might create a group called “Subjective” or “Initial Assessment”, and add fields like Chief Complaint, Current Symptoms, and PHQ-9 Score. You could then click Add Field to define an Objective section field. 

Finally, you might create an “Assessment/Plan” group with fields like Assessment and Plan. The CapMinds guide suggests including sections for “chief complaints, history of current illness, mental status exam, assessment, and plan,” using radio buttons for mood ratings and textboxes for narrative parts. You can also embed standardized screens if desired.

As you add each field, click Save New Field to commit it. Arrange fields using the Order number and Label/Data Column widths to control layout. It’s helpful to leave the encounter form open in another window while designing, so you can quickly switch back and forth: after saving changes, reopen the form in a patient encounter to see your fields and labels in context. 

Repeat adding groups and fields until all necessary data points are captured. When finished, click Save Changes on the layout editor to finalize the form structure

Step 2: Use Custom SOAP Notes During OpenEMR Patient Encounters

After building your form, you can start using it in patient encounters. In an appointment, click the patient’s name to open their dashboard, then click Create Visit or Arrived to start a new encounter. 

On the Encounter Summary page, you will see the encounter forms listed, plus drop-downs for adding new forms. OpenEMR comes with default forms, but it also allows your custom forms to appear in that menu. Use the Clinical drop-down to find and select your new form. The form will open in the entry pane; fill in the fields as with any encounter form, then click Save. The saved note will then appear listed under the patient’s encounter with a summary of its contents.

With your custom SOAP form in place, providers can document mental health visits using your tailored layout. You can further refine the form over time, for example, adding new fields or adjusting defaults by editing the layout, without affecting older notes. This LBV approach avoids having to hand-code PHP; instead, you maintain the form entirely through OpenEMR’s admin interface.

Step 3: Build an OpenEMR SDOH Screening Form

Mental health providers also benefit from routinely capturing Social Determinants of Health. OpenEMR provides a “Social Screening” form as a contributed example to measure SDOH factors. This form breaks SDOH into five domains and is designed to be easy for both patient and provider. It can even be set up to allow patient self-entry via the patient portal.

• To use this form, go to Administration → Forms. 
• In the list of available encounter forms, look for “Social Screening Tool”. 
• Click to register or install it if needed, then enable the form. 
• Once enabled, you will see Social Screening as an option in the form-selection menus during an encounter. 
• Patients can then complete it, and the data will be saved like any other form.

If you prefer to customize which SDOH questions are asked, you could also create your own LBV form for SDOH screening following the same process: Admin→Lists (add a new SDOH form name) and Admin→Layouts. Each field might be a checkbox or a yes/no question. For instance:

• Do you have stable housing? Yes/No
• Do you have difficulty getting enough food? Yes/No 
• Or scaled questions like “How hard is it for you to pay rent?” 

However, using the built-in Social Screening form has advantages: its structure and questionnaires are based on public health standards, and future OpenEMR releases will map its answers to standard FHIR codes for interoperability.

Step 4: Capture and Track Social Determinants of Health Data in OpenEMR

Once the Social Screening form is enabled, providers add it to an encounter just like any form. Under the Miscellaneous or Clinical menu in the encounter summary, select “Social Screening Tool” and click Open. The form will present questions covering each SDOH domain. 

For example, it might ask about employment, education level, housing stability, access to health care, neighborhood safety, and social support. By design, this form tracks changes over time, allowing you to compare a patient’s SDOH profile from visit to visit. When completed, it may show a summary of “risk” areas or scores that highlight vulnerabilities.

It’s important to integrate SDOH screening into your workflow. You might include it for new intakes and periodic updates. OpenEMR’s Social Screening form even comes with a corresponding report to list patients by risk factors. Encourage staff to explain to patients why the screening is done, studies show patients appreciate knowing their social needs are being addressed. If you enable the patient portal, patients can fill out the SDOH questionnaire at home before visits, freeing up in-clinic time (the form automatically creates a portal template upon activation.

Benefits of Custom SOAP Notes for Mental Health Providers

Custom SOAP note templates in OpenEMR offer several key advantages for behavioral health clinics:

• Consistency and Clarity: Standardized sections ensure clinicians record information in predictable places. This makes notes simpler to read and review. A SOAP note has the advantage of organizing information so that it is immediately accessible, allowing clinicians to monitor the patient’s status more effectively.
• Better Communication: Using structured notes allows care teams to communicate more effectively. When multiple specialists review a patient, a consistent format means everyone “stays aligned” on the treatment plan and findings. This is especially important in the realm of mental health, where patients may receive therapy from primary care doctors, psychiatrists, and therapists.
• Tailored Data Collection: Custom forms can be used to collect mental health-specific information such as risk assessments, psychotherapy progress notes, and depression/anxiety ratings. For example, GAD-7 or PHQ-9 score fields can be added immediately to the encounter form. This ensures important outcomes and screening tools are part of routine documentation.
• Efficiency and Compliance: When only the necessary fields are available, documentation may be filled more quickly and with fewer errors. It also helps to ensure compliance with invoicing and privacy rules by incorporating relevant data elements. Finally, extensive and well-structured SOAP notes enable better treatment planning and long-term monitoring of patient progress.

These benefits together mean that mental health providers using OpenEMR’s custom SOAP note forms can streamline their workflow and improve quality of care by integrating behavioral health–specific information into the EHR.

Mental Health Documentation Fields to Include in Custom Forms

When designing a personalized SOAP note form for mental health, consider using sections and fields such as:

• Subjective criteria include chief complaint, history of current disease, symptoms, descriptions of mood or affect, changes in eating and sleeping patterns, psychosocial environment, and standardized screen results.
• The goal of the Mental Status Exam is to assess appearance, behavior, speech, mood, affect, thought content, cognition, and any relevant measurements or vital signs. For example, note the patient’s affect, eye contact, or any physical signs observed.
• Assessment: Diagnostic impressions, risk assessments, and severity impressions. Clinicians summarize information to make a diagnosis or identify problems.
• Plan: Patient education or homework assignments, safety precautions, treatment plans and interventions, referrals, and follow-up appointments.
• Additional fields can be added based on the needs of the practice, such as group therapy or progress notes, discharge planning, or program specifics. You might also include social history items if not captured elsewhere.

A mental health SOAP form might have sections for “chief complaints, history of current illness, mental status exam, assessment, and plan,” using radio buttons or scales for mood and text boxes for narrative entries. Including the right fields up front ensures that all clinically relevant information is consistently documented.

CapMind’s OpenEMR Customization and Integration Service

CapMinds OpenEMR solution equips clinicians with the best features and integration options. It makes their workflows more efficient and filtered. 

The integrated features will allow them to combine the ability of patient record management with conceptual and concurrent reminders. 

This enhances the process of decision-making and improves patient care and quality.

• At CapMinds, OpenEMR custom solutions are developed with much curation and accuracy to match the special practice needs.
• It will be low-cost and the perfect budget solution for your practice’s long-term future.
• CapMinds OpenEMR prioritizes secure data management & ensures compliance with industry regulations, offering healthcare providers peace of mind.

Get the best technologies and HIPAA-compliant and efficient OpenEMR that can be tailored to fit your practice from CapMinds. 

Our OpenEMR services facilitate a Modern User Interface (UI), customization, production support & training. Also facilitates billing, report & specialty enhancements, clearing house integrations, e-prescription, cloud, and more.

“Get the most experienced, proven, and perfect professional support for your OpenEMR.”

Talk To Our openEMR Experts

FAQs

How do you create a custom SOAP note form in OpenEMR?

Use the Layout-Based Visit form system. Go to Administration → Lists → Layout-Based Visit Forms, add a new form with a unique ID and name, then save. Next, open Administration → Layouts, select your form, and add groups and fields as needed.

What fields should be included in a mental health SOAP note template?

Include the Subjective, Objective, Assessment, and Plan parts. Key data is covered, for example, by incorporating sections such as “Chief Complaint,” “History of Present Illness,” “PHQ-9 Score,” “Mental Status Exam,” and “Assessment/Plan.” Tailor fields to capture psychosocial details, symptom changes, and safety planning.

Does OpenEMR support Social Determinants of Health screening forms?

Yes. OpenEMR includes a Social Screening Tool encounter form for SDOH. It can be enabled via Administration→Forms and used in encounters. Patients can complete it via the portal. The form covers domains like housing, food, education and is based on public health standards. Its answers map to standard FHIR codes, enabling structured SDOH data capture.

Can OpenEMR custom forms be used for behavioral health documentation?

Absolutely. Mental health professionals can construct or alter encounter forms to fit their specialized workflows thanks to OpenEMR’s modular nature. You can create treatment plans, progress notes, intake surveys, and more in addition to SOAP notes. For example, common behavioral health templates can be implemented as LBV forms. This flexibility is central to OpenEMR behavioral health documentation, allowing tailored EHR views for therapists and psychiatrists.

What are the benefits of custom SOAP notes for mental health providers using OpenEMR?

Custom SOAP templates improve the quality and efficiency of clinical documentation. Structured notes ensure key information is documented consistently, making care easier to follow. Furthermore, they improve patient tracking by including data specific to mental health into the EHR. To summarize, tailored SOAP notes in OpenEMR encourage better treatment planning, consistency between sessions, and clearer communication among clinicians, all of which contribute to better patient care.