SOAP Notes for Borderline Personality Disorder: Template + Examples (2026)
Overview
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Short answer: a SOAP note for borderline personality disorder (BPD) has four parts. Subjective: the client’s report of emotions, urges, self-harm, suicidal thoughts, relationships and skills use since the last session, often from a diary card. Objective: what you observed (affect, engagement, any visible injuries), scores such as the BSL-23 and the interventions you used, such as a chain analysis. Assessment: your judgment about severity and change, the links in the chain that led to target behaviors, and your suicide risk formulation. Plan: the skills to practice, safety plan updates, coordination and when you will repeat measures.
Record behaviors in specific, neutral terms (“cut her forearm once on Saturday after an argument”), not labels such as “manipulative” or “attention-seeking.” Clear, behavioral notes help the next clinician, support medical necessity and stay fair to the client if they read their record.
What to document in a SOAP note for borderline personality disorder
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Diary card: emotions, urges, self-harm, suicidal thoughts and skills used; key events since the last session | “No self-harm for 10 weeks; urge 3/5 after workplace feedback; used paced breathing and phone coaching before acting.” |
| Objective | Affect and engagement, visible injuries as observed, BSL-23 score and the interventions used | “BSL-23 mean 1.8 (2.5 at intake). Chain and solution analysis of Wednesday’s interrupted self-harm urge; rehearsed returning to the task.” |
| Assessment | Severity and change, the links that led to the behavior, suicide risk formulation | “No self-harm for 10 weeks; help-seeking improved, work avoidance persists; acute suicide risk low today, chronic risk elevated.” |
| Plan | Skills to practice, safety plan, coordination and repeat measures | “Check the facts and practice the agreed first step on a feedback task; follow the safety plan; diary card daily; BSL-23 monthly.” |
Safety. People with BPD have a high lifetime risk of suicide, and self-harm without suicidal intent still needs a suicide assessment each time. Ask directly and record the answer. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. Record self-harm in concrete terms: method, number of times, whether there was any suicidal intent, and wound care. Severe bleeding, bleeding that cannot be stopped, or an overdose is an emergency: call 911. A deep wound or signs of infection need prompt medical evaluation. Distinguish chronic risk from acute risk in your formulation. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document SOAP Notes for Borderline Personality Disorder
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for borderline personality disorder, capture the client's personal report of current emotional state, interpersonal difficulties, impulsivity, and any recent experiences of abandonment or identity disturbance.
- Report of mood fluctuations and intensity of emotional responses since last session
- Descriptions of recent interpersonal conflicts or fears of abandonment
- Client's self-reported impulsive behaviors or urges (e.g., spending, substance use, self-harm)
- Identification of specific triggers that led to emotional dysregulation or crises
- Client's insight into patterns of unstable self-image or feelings of emptiness
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In the Objective section for borderline personality disorder, document observable behaviors, affect, speech patterns, and use of clinical tools or therapeutic approaches during the session.
- Observation of affective instability, such as rapid mood shifts or tearfulness
- Noted client engagement with dialectical behavior therapy (DBT) skills or other modalities
- Presence of nonverbal cues indicating distress (e.g., agitation, restlessness, avoidant eye contact)
- Documentation of any self-injurious marks or physical evidence of impulsive acts
- Use of structured assessments or rating scales specific to emotional regulation or borderline symptoms
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
The Assessment section for borderline personality disorder should synthesize clinical impressions, evaluate treatment response, and assess risk, incorporating client progress and diagnostic clarity.
- Evaluation of the client’s current level of emotional regulation and impulse control
- Clinical impression regarding stability of interpersonal relationships since last session
- Assessment of suicidal or self-harm risk based on client statements and behaviors
- Progress or setbacks in applying coping strategies or therapeutic skills
- Consideration of differential diagnoses or comorbid conditions affecting symptom presentation
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
For borderline personality disorder, the Plan section outlines targeted interventions, homework assignments, safety planning, referrals, and scheduling to support ongoing stabilization and skill development.
- Assignment of specific DBT or other therapeutic homework focused on emotion regulation
- Development or revision of a safety plan addressing self-harm or suicidal ideation
- Referral to psychiatry for medication evaluation or management if indicated
- Scheduling of follow-up sessions with emphasis on consistency and crisis intervention
- Adjustment of therapeutic goals or modalities based on client progress and engagement
DAP Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
BIRP Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
Progress Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
SIRP Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
GIRP Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
PIE Notes for Borderline Personality Disorder
Alternative format for documenting borderline personality disorder
Example SOAP note for borderline personality disorder (DBT chain analysis)
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 32, borderline personality disorder (F60.3). Individual session in month 7 of comprehensive dialectical behavior therapy (DBT), 50 minutes, in person; attends a weekly skills group and has phone coaching under the program agreement. No psychiatric medication. Treatment-plan targets: (1) maintain no self-harm; (2) use a coping skill and seek coaching before acting when urges reach 3/5; (3) return to an interrupted work task after feedback; (4) BSL-23 below 1.5.
Subjective: Diary card reviewed: no self-harm for 10 weeks. On Wednesday, her supervisor returned a report for corrections. Client thought “One mistake means I will lose my job,” felt shame at 8/10 and had an urge to cut rated 3/5. She stepped outside, used paced breathing and called the DBT coach before acting; the urge fell to 1/5. Returned to work but avoided the report until the next morning. Said, “I asked for help before it got worse, but I still hid from the task.” Asked directly: denies current suicidal thoughts, plan, intent or preparatory behavior and any since the last session; current self-harm urge 0/5. Reports one suicide attempt by intentional overdose at 19, none since. No firearm access. Under the agreed means-safety plan, her partner secures sharps and extra medication; she reports no other accessible supply. Names her partner and a close friend as supports, and keeping her job and caring for her dog as reasons for living.
Objective: BSL-23 mean: 1.8 (2.5 at intake). Neatly dressed; oriented; speech normal; thought process linear; tearful while discussing the feedback and settled by the close. Interventions: reviewed the diary card; chain analysis of Wednesday’s urge (vulnerability: poor sleep; prompting event: the returned report; links: a prediction of being fired, shame, an urge to withdraw and an urge to cut; paced breathing and coaching interrupted the chain before self-harm, while avoidance of the report remained); solution analysis identifying checking the supervisor’s actual request and asking one clarifying question; check the facts (the feedback asked for corrections and did not threaten dismissal); rehearsed approaching the task with a brief first step instead of hiding from it; reviewed the written safety plan and means-safety arrangements.
Assessment: BPD, improving: no self-harm for 10 weeks, and skills use plus coaching came before action during this week’s urge, supporting progress on targets 1 and 2. Target 3 is not met: the report was put off until the next day. BSL-23 is down 0.7 and still above the target of 1.5. Suicide risk formulation: chronic risk remains elevated because of the past attempt and history of self-harm. Acute risk judged low today, given no current suicidal thoughts, plan, intent or preparation, no current self-harm urge, reduced access to means, active help-seeking and available supports. Recent urges still need monitoring; a lower score does not by itself establish safety. Reassess every session.
Plan: Continue weekly individual DBT and skills group; next individual session in one week. Complete the diary card daily. For the next manageable feedback task, check the facts and take the agreed brief first step, recording whether avoidance changes. Use the written safety plan and phone coaching per the program agreement if self-harm urges return; review means access at the next contact. If suicidal thoughts or escalating urges arise, she will contact the clinic or call or text 988; for imminent danger or if she cannot stay safe, she will call 911 or go to the nearest emergency department. Repeat BSL-23 monthly.
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Tips for SOAP Notes for Borderline Personality Disorder
Use behavioral, neutral language
Describe what happened, when and how often. Avoid labels such as “manipulative” or “attention-seeking,” which do not help the reader and can harm the client.
Record every self-harm episode
Note method, number, timing, any suicidal intent and wound care. Count episodes so change over time is visible.
Separate chronic and acute risk
BPD often carries elevated chronic suicide risk. Say what makes today’s acute risk higher or lower than usual.
Summarize the chain analysis
List the vulnerability, the prompting event, the key links and the consequences in a few lines, and the alternative skills identified. Record chains for urges that were interrupted, not only for behaviors that happened.
Track a repeated measure
Use the diary card counts and a brief scale such as the BSL-23 so progress is not only described in words.
Write down means and storage
Record access to blades, medications and firearms, what the client agreed to do and when you will check it.
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Further Reading
- DSM-5-TR — Provides the diagnostic criteria and clinical features essential for accurate assessment and documentation of Borderline Personality Disorder.
- APA Documentation Guidelines — Offers best practices for clinical documentation, including SOAP notes, relevant to mental health professionals treating personality disorders.
- SAMHSA — Contains resources on evidence-based treatment approaches and documentation standards for behavioral health conditions including BPD.