SOAP notes are one of the most widely used formats for clinical documentation in mental health settings. Originally developed for medical records, the SOAP format has been adapted for therapy and provides a structured way to document client encounters.

What Are SOAP Notes?

SOAP is an acronym that stands for:

  • Subjective: What the client reports about their experience
  • Objective: Observable facts and clinician observations
  • Assessment: Clinical interpretation and progress evaluation
  • Plan: Treatment plan and next steps

Writing the Subjective Section

The Subjective section captures the client's perspective in their own words. This includes:

  • Chief complaint or reason for visit
  • Mood and emotional state as reported by the client
  • Events since the last session
  • Response to previous interventions or homework
  • Any new concerns or issues raised

Example: "Client reports feeling 'more hopeful' this week. States she used breathing exercises twice when feeling anxious at work. Notes improved sleep (6-7 hours vs. 4-5 hours last week). Expresses continued concern about upcoming family visit."

Writing the Objective Section

The Objective section includes observable, measurable information:

  • Appearance and grooming
  • Affect and mood presentation
  • Behavior during session
  • Speech patterns
  • Any assessment scores or measurements

Example: "Client arrived on time, appropriately dressed. Affect brighter than previous session; smiled several times. Eye contact appropriate. Speech normal rate and volume. PHQ-9 score: 8 (down from 12 at intake)."

Writing the Assessment Section

The Assessment is your clinical interpretation:

  • Progress toward treatment goals
  • Response to interventions
  • Diagnostic impressions
  • Risk assessment if relevant
  • Clinical formulation

Example: "Client demonstrating progress in anxiety management through consistent use of coping strategies. Improvement in sleep and successful real-world application of breathing techniques indicates positive treatment response. Family-related anxiety remains primary focus area."

Writing the Plan Section

The Plan outlines next steps:

  • Interventions to continue or modify
  • New techniques to introduce
  • Homework assignments
  • Referrals if needed
  • Next session scheduling

Example: "Continue weekly sessions. Next session: role-play strategies for family interactions. Homework: daily 5-minute breathing exercise, journal positive coping moments. Follow up on psychiatry referral."

Common Mistakes to Avoid

  1. Mixing subjective and objective: Keep client reports separate from your observations.
  2. Being too vague: Use specific, measurable language.
  3. Including too much detail: Focus on clinically relevant information.
  4. Forgetting the plan: Every note should end with clear next steps.
  5. Using jargon without explanation: Notes should be understandable to other providers.

Tips for Efficiency

Writing SOAP notes doesn't have to take forever. Here are some strategies:

  • Use templates: Start with a consistent structure.
  • Document key points during session: Brief notes help later.
  • Use AI assistance: Tools like InterSession can generate draft notes from session recordings.
  • Batch your documentation: Write notes in focused blocks rather than scattered throughout the day.
"The best note is one that serves its purpose without becoming a burden. Aim for clarity and completeness, not perfection."

Conclusion

SOAP notes provide a reliable framework for therapy documentation. With practice and the right tools, you can create thorough, professional notes efficiently — leaving more time for what matters most: your clients.