What Are SOAP Notes?
SOAP notes are the backbone of clinical documentation in mental health practice. The acronym stands for Subjective, Objective, Assessment, and Plan — the four sections that organize your observations and thinking into a structured record.
Developed in medical practice and adapted for mental health, SOAP notes serve multiple functions: they document the clinical encounter for the client's record, enable continuity of care between sessions, demonstrate clinical reasoning, support treatment planning, and create a legal record of your work. Whether you work in private practice, a clinic, a hospital, or via teletherapy, mastering SOAP notes is essential to your practice.
Well-written SOAP notes demonstrate that your work is thoughtful, organized, and professionally executed. They're not just paperwork — they're documentation of quality care.
To write a SOAP note, record the client's reported experiences and concerns in the Subjective section, your own observations such as appearance, affect, and behavior in the Objective section, your clinical interpretation and progress toward treatment goals in the Assessment, and the next steps, interventions, and follow-up in the Plan. Keep the Objective section factual and reserve clinical judgment for the Assessment, and document any safety concerns explicitly. Write the note promptly after the session so it stays accurate and clearly reflects the care provided.
The Four Components Explained in Detail
1. Subjective (S) — What the Client Tells You
The Subjective section captures the client's perspective, their complaints, concerns, and self-reported experiences. This is where you document what the client presents to you in the session.
What to include:
- Chief complaint or reason for today's session
- How the client is feeling and what's bothering them
- Events or stressors that occurred since the last session
- Changes in symptoms or functioning
- Client's perspective on their progress and treatment
- Relevant life events, relationships, or work situations
- Client quotes when they effectively illustrate their experience
How to write it: Use the client's language when appropriate, but maintain professional documentation standards. You can paraphrase rather than transcribe, but capture the essence of what the client is experiencing. This section should reflect their subjective reality — their feelings, perceptions, and self-assessment.
2. Objective (O) — What You Observe and Measure
The Objective section contains your clinician observations — what you see, hear, and measure that's independent of the client's subjective report. This is based on your clinical observations during the session.
What to include:
- Appearance (grooming, dress, hygiene)
- Affect and mood presentation (flat, congruent, appropriate)
- Speech patterns (rate, volume, flow)
- Psychomotor activity (restless, calm, organized)
- Orientation and cognitive functioning
- Behavioral observations (agitated, withdrawn, engaged)
- Any standardized assessment results or measures used
- Progress on specific treatment goals or homework
- Session attendance and engagement level
How to write it: Be specific and behavioral. Avoid making judgments in this section — that's for the Assessment. Say "Client appeared anxious, fidgeting in seat" rather than "Client is anxious." Use descriptive language that paints a clear clinical picture.
3. Assessment (A) — Your Clinical Interpretation
The Assessment section is where you synthesize the subjective and objective data and provide your clinical interpretation. This is the "thinking" section where you demonstrate your clinical reasoning.
What to include:
- Your clinical impression of the client's current status
- How the information relates to the presenting problem
- Progress toward stated treatment goals
- Diagnostic considerations and formulation
- Any risk factors or safety considerations
- Relevant theoretical framework or clinical model you're using
- Barriers to progress or positive developments
- Collaboration with other providers (if relevant)
How to write it: This is where you show your expertise. Connect what you observed and heard to your clinical understanding. Explain your reasoning. If you're concerned about a particular issue, articulate why. If you're pleased with progress, explain what indicates improvement. This section demonstrates your clinical competence and professional judgment.
4. Plan (P) — What Happens Next
The Plan section outlines your clinical next steps and treatment direction. It's action-oriented and specific.
What to include:
- Specific therapeutic interventions for the next session
- Homework or between-session activities for the client
- Specific treatment goals or focus areas
- Frequency and schedule of ongoing sessions
- Any referrals or consultations needed
- Medication management or psychiatric consultation (if applicable)
- Safety planning or crisis protocols (if indicated)
- Timeline for re-evaluation or progress assessment
How to write it: Be concrete and actionable. "Client will practice the grounding technique daily" is better than "Work on coping skills." Specific plans show intentional treatment design and give both you and the client clear direction for the work ahead.
Key Takeaway: SOAP is a common progress-note format in mental health. Its four sections (Subjective, Objective, Assessment, Plan) give a record that supports continuity of care and that payers, auditors or other providers can follow.
SOAP Note Example for Anxiety Session
Here is a fictional example of a SOAP note for an individual therapy session with an adult client with generalized anxiety disorder. No real client is described.
Subjective
Sarah presented today reporting increased anxiety over the past week, particularly related to an upcoming presentation at work. She described lying awake at night worrying about "messing it up" and said she's been "snappy" with her partner. She acknowledged using her breathing exercises a few times but stated, "They're not helping much." Sarah reported that the anxiety "comes out of nowhere" and that she has difficulty focusing at work. She stated this is the worst she's felt in about three weeks. She remains committed to therapy and is motivated to manage her anxiety more effectively. When asked, she denied thoughts of suicide or self-harm.
Objective
Client arrived on time, appropriately dressed, with good hygiene. Affect was anxious and congruent with her reported mood. She demonstrated psychomotor restlessness, shifting in seat frequently. Speech was rapid but coherent and easy to follow. Eye contact was good and sustained. She appeared engaged throughout the session and followed the therapeutic direction. Client completed the GAD-7 screen today scoring 16/21, indicating severe anxiety (previous week: 14/21, moderate). She completed her between-session homework of tracking anxiety triggers 5 of 7 days. Intervention: introduced a thought record for her worry about the presentation; with prompting she identified one catastrophic thought and wrote one balanced alternative. No signs of psychosis or thought disorder observed.
Assessment
Sarah's presentation is consistent with generalized anxiety disorder, with anxiety manifesting through both physical symptoms (sleep disruption) and cognitive symptoms (worry, concentration difficulties). Her uptick this week appears situationally triggered (work presentation) but reflects her underlying difficulty managing worry. Positive prognostic indicators: She maintains insight, follows through on homework most days, demonstrates ability to use some coping skills, and expresses commitment to change. The GAD-7 score in the severe range, up slightly from the prior week, suggests symptoms are currently elevated and that continued, possibly intensified, intervention is needed. Her relationship strain is a secondary consequence of unmanaged anxiety. She denied thoughts of suicide or self-harm when asked, and no other safety concerns were identified this session. Diagnosis: generalized anxiety disorder (ICD-10-CM F41.1).
Plan
- Therapeutic focus: Introduce cognitive challenging techniques to address catastrophic thinking about the work presentation. Specifically, practice the "Realistic Evaluation" worksheet with focus on her worried thoughts about performance.
- Between-session: Client to use the thought record daily (minimum 1-2 worry instances) to identify and challenge automatic thoughts. She will practice the extended breathing exercise (5-minute version) twice daily and log when she does this.
- Medications: Client not currently on psychiatric medications. Will continue to monitor for potential need for consultation.
- Next steps: Continue weekly sessions. Will reassess GAD-7 in 4 weeks. If her distress escalates or thoughts of suicide or self-harm emerge before the next appointment, she has the 988 Suicide & Crisis Lifeline number (call or text 988) and will call 911 in an emergency.
- Homework success strategy: Client identified that logging when she uses techniques is helpful as a reminder, so we'll continue with this practice.
Notice how this note flows logically: we understand Sarah's presenting concern (Subjective), we have clinical observations that support it (Objective), we explain what the increase in her anxiety means clinically and what is helping (Assessment), and we have a clear plan for next steps (Plan).
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Tips for Writing Better SOAP Notes
Be Specific, Not Generic
Vague SOAP notes are hard for the next reader to use. Instead of "Client discussed anxiety," write "Client reported increased anxiety about the upcoming presentation, describing racing thoughts and sleep disruption." Specifics matter.
Use Appropriate Clinical Language
Your notes are professional documents. Use clinically appropriate terminology, but don't overuse jargon. "Affect congruent" is appropriate; "the client was having big feelings" is not.
Connect the Four Sections
Your Assessment should directly reference the Subjective and Objective data. Your Plan should flow logically from your Assessment. The note should tell a coherent clinical story.
Focus on Clinical Content
SOAP notes should document clinical content, not administrative details. How the client paid their bill goes on an invoice, not in the clinical note. What you discussed in therapy goes in the note.
Balance Detail with Efficiency
Comprehensive notes aren't the same as long notes. Be thorough about clinically relevant information; be concise about everything else. For a routine session that is often a short paragraph or a few lines per section.
Write Objectively in the Objective Section
A frequent mistake is including subjective interpretation in the Objective section. Save your clinical judgment for the Assessment.
Update Progress Systematically
Each note should contain some reference to the treatment plan and progress toward goals. This creates a visible record of clinical change over time.
Common Mistakes to Avoid
Mistake 1: Copying and Pasting Standard Text
While templates are helpful, copying identical text into every note creates documentation that doesn't reflect individual client experiences. Your notes should be tailored to each client and session.
Mistake 2: Mixing Sections
Putting assessment content in the Subjective section or clinical opinion in the Objective section creates confusion. Keep sections distinct and purposeful.
Mistake 3: Missing Safety Information
If safety is relevant (suicidal ideation, substance use, abuse), it should be explicitly documented. Omitting safety information is a significant documentation gap.
Mistake 4: Vague Treatment Plans
A plan that says "Continue therapy" doesn't provide direction. Specific plans like "Teach cognitive restructuring techniques focusing on catastrophic thinking" demonstrate intentional treatment.
Mistake 5: Writing Notes Days Later
Document immediately after the session. Delayed notes are less accurate and less detailed.
Mistake 6: Focusing on Narrative Instead of Clinical Content
SOAP notes should be clinical documents, not client stories. Include relevant information; exclude irrelevant details about the client's life that don't relate to their treatment.
Mistake 7: Forgetting About Multiple Audiences
Your SOAP note may be read by insurance companies, other providers, your supervisor, or (potentially) a courtroom. Write assuming it could be reviewed by anyone with legitimate clinical interest in your client's care.
How AI Can Help with SOAP Notes
Artificial intelligence is transforming clinical documentation in meaningful ways. AI-powered documentation tools can assist with SOAP note writing by:
Organizing Your Thinking
AI tools can help structure the information you supply into the four SOAP sections. Review the draft for omissions and add any relevant details from the care you actually provided. They can prompt you for information you might otherwise miss.
Suggesting Clinical Language
AI tools suggest appropriate clinical phrases, helping maintain professional standards and consistency.
Reducing Writing Time
Instead of typing full notes from scratch, you can use voice input or structured templates with AI.
Ensuring Consistency
AI can help keep formatting and terminology consistent across notes; you still check that each note has the elements your payer or agency requires.
Supporting Compliance
AI can organize the information you supply. Check that the draft accurately records any risk screening, progress and assessment you actually performed, and add missing details yourself.
Important: AI is an assistant, not a replacement for clinical judgment. Your clinical thinking, observations, and assessment remain the core. AI amplifies your work; it doesn't replace it. Always review AI-generated content and edit for accuracy.
Key Takeaway: A clear SOAP note makes your clinical reasoning and the medical necessity of the service easier to follow when a payer or auditor reviews the record. Tools like MentalNote can draft a SOAP note for you to review and edit.
SOAP Note FAQ
What does SOAP stand for in mental health?
Subjective, Objective, Assessment and Plan. Subjective is what the client reports, Objective is what you observe and measure, Assessment is your clinical interpretation, and Plan is what happens next. A SOAP note is a progress note and part of the client record.
What goes in the Objective section of a therapy SOAP note?
What you observe or measure yourself: appearance, affect, behavior, speech, engagement, any screening scores such as the PHQ-9 or GAD-7, homework completion, and the interventions you used with how the client responded. Keep your interpretation for the Assessment.
How do you describe emotional struggles in a SOAP note?
Put the client’s own description in Subjective, ideally with a short quote, such as “I can’t switch my mind off at night.” Put what you saw in Objective, such as tearful, restless or flat affect. Then explain in Assessment what the pattern means for the diagnosis and treatment goals.
How long should a mental health SOAP note be?
Long enough to show the service, what the client reported and showed, your assessment and the plan. For a routine outpatient therapy session that is often a short paragraph or a few lines per section. Your payer or agency may require more.
What is the difference between a SOAP note and a DAP note?
A DAP note combines the client’s report and your observations into one Data section, followed by Assessment and Plan. SOAP keeps them apart as Subjective and Objective. Both are progress notes; use the one your agency or payer expects.
Is a SOAP note the same as a psychotherapy note?
No. A SOAP note is a progress note and part of the client record. Under HIPAA, psychotherapy notes are a therapist’s separate process notes, defined in 45 CFR 164.501. Most uses and disclosures of psychotherapy notes need the client’s specific authorization (45 CFR 164.508), and they are excluded from the client’s right of access (45 CFR 164.524). Keep them apart from the record.
Related Resources
Ready to apply these SOAP note principles? Download our free SOAP note template to get started with a professional structure. Then try the AI SOAP note generator, which drafts a SOAP note from a recorded session for you to review and edit.
Not sure if SOAP is the right format for you? Compare SOAP vs DAP note formats to find the best fit for your practice.