What should a SOAP note for chronic pain include?

Subjective: the client’s report of pain, sleep, mood and activity since the last session. Objective: observed pain behaviors and affect, scores such as the PEG and the interventions used. Assessment: function, the psychological factors that maintain distress and your suicide risk formulation. Plan: next steps, tasks, coordination with the medical team and repeat measures.

What is the PEG pain scale?

The PEG is a three-item pain scale: average pain intensity, interference with enjoyment of life and interference with general activity over the past week, each rated 0 to 10. The score is the average of the three items, so it tracks pain and function together. It supports monitoring, not diagnosis.

How do you document acceptance and commitment therapy for chronic pain?

Name the ACT processes you worked on, such as defusion, acceptance or values, and the exercise used. Record the client’s chosen values-based actions and whether they did them. In Assessment, describe how avoidance or fusion with thoughts affects function, and avoid claiming change in daily life from an in-session exercise alone.

What diagnosis do therapists use for chronic pain?

Therapists usually do not diagnose the pain condition itself. They record the mental health diagnosis their assessment supports, such as depression, anxiety, somatic symptom disorder, or psychological factors affecting other medical conditions (F54), alongside the medical diagnosis made by the physician.

Should a therapy note mention pain medication?

Record the medication the client reports, who prescribes it, side effects or concerns they raise and any consented communication with the prescriber. Record safe storage if medications are a means risk. Do not recommend dose changes in a therapy note.

SOAP Notes for Chronic Pain: Template + Examples (2026)

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Overview

This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.

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Short answer: a SOAP note for chronic pain in therapy has four parts. Subjective: the client’s report of pain, sleep, mood, activity and how pain affects work, relationships and valued activities since the last session. Objective: what you observed (pain behaviors, affect, engagement), scores such as the PEG and the interventions you used. Assessment: your judgment about function, the psychological factors that make the pain harder to live with (avoidance, catastrophizing, low mood, poor sleep) and current suicide risk. Plan: the next session, between-session tasks, coordination with the medical team and when you will repeat measures.

Therapy notes for chronic pain focus on function and coping, not on curing the pain. The medical diagnosis and medication belong to the treating physician; your note records the psychological diagnosis you assessed (for example depression, anxiety, or psychological factors affecting a medical condition) and how treatment changes what the client can do.

What to document in a SOAP note for chronic pain

Chronic pain details to document in a SOAP note, with fictional example wording
Section	What to document	Example wording
Subjective	Pain intensity and pattern, sleep, mood, activity, and the effect of pain on valued activities since the last session	“Average pain 6/10; skipped her sister’s birthday dinner because ‘I’d only ruin it.’ Gardened 15 minutes once.”
Objective	Observed pain behaviors, affect and engagement, PEG score, and the interventions used	“PEG 6.3 today (7.7 at intake). Shifted position often; affect tired but engaged in the exercise.”
Assessment	Function and change, maintaining factors such as avoidance or catastrophizing, and your suicide risk formulation	“Function improving; avoidance of social plans maintains low mood; acute risk low.”
Plan	Next session focus, tasks, coordination with the medical team and repeat measures	“Try gardening for up to 15 minutes on two days, within the rheumatologist’s activity guidance; PEG every session; update rheumatologist with consent.”

Safety. People living with chronic pain have a higher risk of suicide, and many have access to medications that could be used in an overdose, so 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. New loss of bladder or bowel control, inability to urinate, numbness in the groin or inner thighs (saddle numbness), or new severe or worsening leg weakness can signal a medical emergency: arrange immediate emergency department evaluation, call 911 if emergency transport is needed, and record the symptoms, timing and action taken. Route other new or changing physical symptoms promptly to the treating medical clinician. 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 Chronic Pain & Psychological Factors

Subjective

Record the client's reported symptoms, concerns, mood, and perspective in their own words

When documenting the Subjective section for chronic pain, capture the patient’s personal experience of pain, including descriptions of symptoms, perceived triggers, and emotional responses that influence their condition.

Describe the quality, intensity, and location of pain as reported by the patient.
Identify specific activities or environmental factors that exacerbate or relieve the pain.
Document the duration and frequency of pain episodes or flare-ups.
Record the patient’s mood, affect, and any reported feelings of anxiety, depression, or frustration related to chronic pain.
Note any patient-reported impact of pain on sleep, daily function, or social interactions.

Objective

Document clinical observations, affect, behavior, appearance, and measurable data

In a psychotherapy SOAP note, record your behavioral observations, measures and psychological interventions. Attribute any physical examination findings or physical treatments to the medical or rehabilitation clinician who assessed or provided them, with the source and date; do not imply that the therapist examined or treated the body.

Note relevant physical findings reported by the treating medical clinician, with the source and date.
Record observed patient behaviors or signs of discomfort during assessment.
Note results from standardized pain scales or functional assessment tools used.
Detail the psychological interventions you provided, such as defusion, values clarification or coping-skills work, and the client’s response.
Record physical changes the client reports, and route new or changing symptoms to the medical team.

Assessment

Provide clinical interpretation, diagnostic impressions, and progress evaluation

The Assessment section for chronic pain should synthesize clinical findings and patient feedback to form diagnostic impressions, evaluate progress, and consider treatment effectiveness or necessary adjustments.

Summarize the psychological factors affecting function and coping; attribute medical explanations of the pain to the treating medical clinician.
Evaluate patient progress relative to previous sessions and treatment goals.
Identify any new or evolving symptoms that may warrant further diagnostic consideration.
Assess patient adherence to prescribed treatments and their response or tolerance.
Note any psychosocial factors influencing pain perception and management.

Plan

Outline treatment strategy, interventions, homework, and follow-up schedule

In the Plan section for chronic pain, outline the intended next steps including treatment modifications, patient instructions, referrals, and scheduling to support ongoing management.

Specify adjustments to pain management strategies or therapeutic interventions.
Provide patient homework or self-care instructions aimed at symptom relief or functional improvement.
Recommend referrals to specialists such as pain management, psychology, or physical therapy as appropriate.
Schedule follow-up appointments or monitoring to assess treatment efficacy.
Document medication concerns and consented coordination with the prescriber; attribute any medication changes to that prescriber.