SOAP Notes for Self-Harm: Template + Examples (2026)
Overview
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Short answer: a SOAP note for self-harm (non-suicidal self-injury, or NSSI) records what the client reported about urges and episodes since the last session and what led to them (Subjective), what you observed, the measures you used and the work done in session (Objective), a risk formulation that assesses suicide risk separately from self-injury (Assessment), and the safety plan and next steps (Plan). Describe self-injury in general clinical terms; method detail rarely adds anything to the record. Every note should show that you asked directly about suicidal thoughts.
NSSI is deliberate injury to one’s own body without suicidal intent, often to relieve intense emotion. It is not a DSM-5-TR mental disorder: it appears in Section III as a condition for further study, and DSM-5-TR lists codes for it as a condition that may be a focus of clinical attention (R45.88 for current nonsuicidal self-injury, Z91.52 for a personal history), used alongside any diagnosis it occurs with, such as a depressive disorder, PTSD or borderline personality disorder. A history of self-injury is a strong risk factor for later suicide attempts, which is why the note should cover suicidal thoughts and not only self-injury. The table shows what goes in each section.
What to document in a self-harm SOAP note
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Urges and episodes since the last session: how often, triggers and what the self-injury did for the client | “Two urges this week; one episode on Tuesday after an argument (about 4 a week at intake). Client: ‘It turned the noise down for a minute.’” |
| Subjective | Suicidal thoughts, asked about directly and separately | “Asked directly about thoughts of suicide: denied current thoughts, plan or intent; no past suicide attempts. Access to means assessed; access concerns addressed in the safety plan.” |
| Subjective | Injuries and medical care, in general terms | “Client reports the injury was superficial, has healed and did not need medical care.” |
| Objective | Presentation, engagement and measures | “Affect anxious at the start, brighter later. C-SSRS screener negative for suicidal ideation and behavior since last contact.” |
| Objective | Interventions used in session | “Chain analysis of Tuesday’s episode; practiced paced breathing; reviewed the safety plan.” |
| Assessment | Risk formulation: suicide risk and risk of injury assessed separately, with the factors behind your judgment | “Acute suicide risk judged low (no current ideation, intent or plan; engaged in treatment); chronic risk elevated by history of self-injury and depression.” |
| Assessment | Progress toward the treatment-plan goals | “Episodes down from about 4 a week at intake to 1 this week; used a skill for 1 of 2 urges.” |
| Plan | Safety plan update, reducing access to means, skills practice, contacts and next session | “Safety plan updated, copy given, 988 included; items used for self-injury kept out of her room; next session in 1 week.” |
If a client reports suicidal thoughts, intent or a plan, an injury that needs medical care, self-injury that is becoming more frequent or severe, or self-injury while intoxicated, assess and act on that risk as your protocol requires (for example a full suicide risk assessment, same-day medical care, more frequent contact or a higher level of care) and document what you did. For a minor, record how parents or guardians were involved, under your state’s law and the confidentiality agreement you made with the client. Include the 988 Suicide & Crisis Lifeline (call or text 988 in the US) in every safety plan. Collaborative safety planning is generally recommended over no-harm contracts, which have little evidence that they prevent self-harm.
How to Document SOAP Notes for Non-Suicidal Self-Injury
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for self harm, capture the client’s own report of their thoughts, feelings, and experiences related to self-injurious behaviors, including any triggers or emotional states preceding the behavior.
- Client’s description of recent urges or impulses to self harm
- Reported emotional triggers or stressors contributing to self harm episodes
- Client’s current mood and affect related to self harm thoughts
- Client’s perception of the function or purpose of their self harm (e.g., relief, expression)
- Client’s report of any recent changes in frequency or severity of self harm behaviors
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In the Objective section, document observable signs, clinical findings, and any therapeutic interventions or assessments conducted during the session related to self harm.
- Any injuries observed or reported, in general clinical terms (body area, healing, whether medical care is needed), without method detail
- Client’s nonverbal behavior and affect during discussion of self harm
- Use of validated assessment tools for self harm risk or severity
- Therapeutic techniques applied to address self harm urges (e.g., grounding, distress tolerance)
- Client engagement level with interventions or coping strategies during session
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
The Assessment section should summarize clinical impressions regarding the client’s self harm behavior, evaluate progress or risk, and integrate diagnostic considerations based on subjective and objective data.
- Risk formulation: suicide risk and risk of injury assessed separately, with the factors behind your judgment
- Evaluation of client’s insight and motivation to change self harm behaviors
- Progress toward previous treatment goals related to self harm reduction
- Consideration of co-occurring diagnoses influencing self harm (e.g., depression, PTSD)
- Client’s response to therapeutic interventions and readiness for next steps
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section outlines the targeted interventions, referrals, and follow-up steps designed to reduce self harm behaviors and support client safety and recovery.
- Development or adjustment of a safety plan addressing self harm urges
- Assignment of coping skill practice or homework related to distress tolerance
- Referral to specialized services if indicated (e.g., psychiatry, crisis intervention)
- Scheduling of follow-up sessions with focus on self harm monitoring
- Modification of treatment goals or therapeutic approaches based on current assessment
DAP Notes for Self Harm
Alternative format for documenting self harm
BIRP Notes for Self Harm
Alternative format for documenting self harm
Progress Notes for Self Harm
Alternative format for documenting self harm
SIRP Notes for Self Harm
Alternative format for documenting self harm
GIRP Notes for Self Harm
Alternative format for documenting self harm
PIE Notes for Self Harm
Alternative format for documenting self harm
Self-harm SOAP note example
Fictional documentation example, not treatment guidance. Adapt it to the session you actually provided and your organization’s requirements.
Subjective: Fictional 20-year-old college student, session 9 of individual therapy using DBT skills; major depressive disorder, recurrent, moderate (F33.1), and nonsuicidal self-injury, current (R45.88), with self-injury since age 15. Treatment-plan goals: no self-injury, using a distress tolerance skill for at least 3 of 4 urges, and attending all classes. Since the last session one week ago, the client reported two urges to self-injure and one episode on Tuesday night after an argument with her roommate (about 4 episodes a week at intake). She described the injury as superficial; it has healed and did not need medical care. For the other urge she used the cold-water skill from TIPP. Client stated: “It turned the noise down for a minute, then I felt worse.” Asked directly about suicidal thoughts: she denied current or recent thoughts of suicide, a plan or intent, and reported no past suicide attempts. Access to means was assessed directly: items she has previously used for self-injury were still accessible; no other access concerns were identified. Attended 9 of 10 classes. Slept about 4 hours the night before the episode.
Objective: Alert and oriented, casually dressed, good eye contact. Affect anxious at the start of the session and brighter when she described using the skill. No injuries visible. C-SSRS screener negative for suicidal ideation and suicidal behavior since last contact. PHQ-9 today 11 (16 at intake). Interventions: completed a chain analysis of Tuesday’s episode (vulnerability: little sleep; prompting event: the argument; key thought: “I can’t stand this”) and identified two points where a skill could have helped; practiced paced breathing; reviewed and updated the safety plan.
Assessment: Self-injury has decreased from about 4 episodes a week at intake to 1 this week, and she used a skill for 1 of 2 urges. Risk of recurrent self-injury remains elevated given the recent episode, urges during the past week and continued access to items she has used for self-injury; the safety plan addresses these factors. Acute suicide risk judged low: she denies current suicidal ideation, intent or plan, has no history of suicide attempts, is engaged in treatment, makes plans for the spring semester and names her sister as a support. Chronic risk remains elevated because of the history of self-injury and recurrent depression; risk would rise with sleep loss, interpersonal conflict, alcohol use or any return of suicidal thoughts. Partial progress toward all three goals.
Plan: Updated the safety plan with the client: warning signs (little sleep, replaying arguments), coping strategies (cold water, a walk, music), people and places for distraction, her sister and the residence advisor to ask for help, the campus counseling after-hours line and the 988 Suicide & Crisis Lifeline (call or text 988). She agreed to keep items she has used for self-injury out of her room, with her sister holding them. Client kept a copy of the plan on her phone. Practice paced breathing daily, keep the diary card and aim for 7 hours of sleep. If suicidal thoughts return, she will use the safety plan and contact the campus counseling after-hours line or call or text 988 for immediate support. She will seek prompt medical assessment for any injury that needs care. For immediate danger or a medical emergency, she will call 911 or go to the nearest emergency department. Next session in one week.
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Tips for SOAP Notes for Non-Suicidal Self-Injury
1. Ask about suicide every time
Ask directly about suicidal thoughts, plans and intent at every session where self-injury is a concern, and record the question and the answer. Self-injury and suicidal thinking can change independently.
2. Describe injuries without method detail
Record frequency, general body area, severity and whether medical care was needed. Method detail rarely changes the plan and can be harmful if others read the record.
3. Record triggers and function
Note what came before each episode and what the self-injury did for the client, for example relief from intense emotion. A chain analysis in the client’s words links the note to the skills you teach.
4. Use a safety plan, not a no-harm contract
Write the plan with the client: warning signs, coping strategies, people and places for distraction, people to ask for help, professional and crisis contacts including 988, and steps to make the environment safer. Record that a copy was given and when it was reviewed.
5. Document means safety and medical care
Record what the client agreed to do about access to items they have used to self-injure, and any referral or follow-up for wound care or other medical needs.
6. Use neutral, respectful language
Write “self-injury” or “self-harm” and describe behavior factually. Avoid phrases like “attention-seeking” or “manipulative,” which are not clinical findings and can affect how others treat the client.
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Further Reading
- SAMHSA — Provides comprehensive resources on mental health treatment and best practices relevant to NSSI clinical care.
- DSM-5-TR — Offers diagnostic criteria and clinical descriptions essential for accurately assessing NSSI behaviors.
- APA Documentation Guidelines — Details standardized clinical documentation practices useful for structuring SOAP notes in mental health settings.