SOAP Notes for Substance Use Disorders
Master soap notes documentation for substance use disorders. This comprehensive guide covers section-by-section documentation best practices, clinical considerations, assessment tools, therapeutic interventions, and common documentation pitfalls specific to substance use disorders.
Quick Answer
SOAP notes are a structured method for documenting clinical encounters, consisting of Subjective, Objective, Assessment, and Plan sections. For substance use disorders, they capture patient-reported symptoms, clinical observations, diagnostic impressions based on DSM-5-TR criteria, and treatment plans including counseling or medication-assisted therapy. Accurate SOAP notes improve continuity of care and meet regulatory documentation standards.
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 substance use SOAP note records the client’s report of use since the last session (substance, days, amount, route), cravings, triggers and recovery activities in Subjective; your observations, any screening scores or test results and the intervention you used in Objective; your clinical judgment about progress, stage of change, withdrawal and overdose risk, and suicide risk in Assessment; and the next steps, referrals and next session in Plan.
Be specific: “2 drinking days, 4–5 standard drinks each” is more useful than “drank less.” Record the diagnosis with its DSM-5-TR severity (for substance use disorders, 2–3 of the 11 criteria is mild, 4–5 moderate and 6 or more severe) and track a repeated measure or count against baseline. Medication for alcohol or opioid use disorder is prescribed by a licensed prescriber, so a counselor’s note records referrals, coordination with consent and what the client reports, not medication decisions. If your program is covered by the federal 42 CFR Part 2 rules, follow them for consent and disclosure.
What to document in a substance use SOAP note
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Use since the last session: substance, days, amount, route | “2 drinking days this week (Fri, Sat), 4–5 standard drinks each; 5 drinking days the week before.” |
| Subjective | Cravings, triggers and recovery activities | “Cravings up to 6/10 after work stress; attended 1 mutual-support meeting.” |
| Objective | Observations, screening scores or test results | “No odor of alcohol, speech clear, gait steady. AUDIT 18 at intake.” |
| Objective | The intervention used | “Motivational interviewing; functional analysis of Friday’s drinking episode.” |
| Assessment | Progress, stage of change and diagnosis with severity | “Alcohol use disorder, moderate (F10.20); drinking days 5 to 2; moving from preparation to action.” |
| Assessment | Withdrawal, overdose and suicide risk | “Denied tremor, sweating or past withdrawal seizures; denied suicidal thoughts.” |
| Plan | Next steps, referrals and next session | “Craving log; urge surfing; 2 meetings; with consent, referral to primary care to discuss medication for alcohol use disorder. Next session in 1 week.” |
Stopping or sharply reducing alcohol, benzodiazepines or other sedatives after heavy regular use can cause dangerous withdrawal, including seizures. Record recent amounts and duration of use, time since last use or reduction, symptoms and withdrawal history. Arrange prompt medical assessment when the use pattern or history suggests withdrawal risk, even without current symptoms; do not advise an unsupervised abrupt stop. Seizures, severe confusion or other signs of imminent danger require emergency care. For opioid use, record overdose risk (for example a return to use after a period of not using) and whether the client has naloxone. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, history, access to means, protective factors and the safety plan. 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 Substance Use Disorders
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for substance use, focus on capturing the client’s self-reported experiences, including cravings, mood states, triggers, and any perceived symptoms related to their substance use.
- Client’s description of recent substance use patterns and frequency
- Reported triggers or situations that increase the urge to use substances
- Client’s mood and affect related to substance use or abstinence efforts
- Presence of withdrawal symptoms as experienced by the client
- Client’s personal goals or concerns regarding their substance use
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
The Objective section should document observable signs, clinical findings, and interventions applied during the session related to substance use.
- Clinician’s observations of client’s physical appearance and hygiene consistent with substance use
- Noted behaviors such as restlessness, sweating, or tremors during the session
- Use of screening tools or standardized assessments for substance use severity
- Application of motivational interviewing or cognitive-behavioral techniques during the session
- Documentation of client’s engagement level and responsiveness to therapeutic interventions
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
In the Assessment section, synthesize subjective and objective information to provide clinical impressions, evaluate progress, and consider diagnostic or treatment implications related to substance use.
- Clinical impression of client’s current stage of change regarding substance use
- Evaluation of client’s progress toward reducing or abstaining from substances
- Consideration of co-occurring mental health disorders impacting substance use
- Assessment of client’s insight and motivation for treatment
- Identification of any risks such as relapse or withdrawal complications
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section should outline specific next steps, treatment goals, referrals, and follow-up plans tailored to address the client’s substance use needs.
- Schedule of upcoming therapy sessions or group meetings focused on substance use
- Homework assignments such as tracking triggers or practicing coping skills
- Referrals to specialized programs such as detox, inpatient treatment, or support groups
- Modifications to the treatment plan based on client progress or setbacks
- Coordination with medical providers for medication-assisted treatment if applicable
Example SOAP Note for Substance Use
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Subjective: Fictional adult client, session 4 of outpatient counseling for alcohol use disorder, moderate (F10.20; 5 of 11 DSM-5-TR criteria at intake), 50 minutes. Treatment-plan goals: (1) no more than 1 drinking day a week, then abstinence by week 12, as the client chose; (2) use a coping step when cravings reach 5/10 or more; (3) attend 2 recovery meetings a week. Client reported 2 drinking days this week (Friday and Saturday, 4–5 standard drinks each) compared with 5 days the week before, and none since Saturday. Cravings peaked at 6/10 after a stressful meeting at work on Friday. Attended 1 mutual-support meeting. Denied other substance use. Said, “I want to get through weekends without drinking.”
Objective: On time, appropriately groomed. No odor of alcohol; speech clear; gait steady; no tremor or sweating observed. Affect mildly anxious and congruent with content. AUDIT 18 at intake (score range 0–40). Used motivational interviewing to explore the client’s reasons for change, and a functional analysis of Friday’s drinking episode (trigger: work stress; thought: “I deserve it”; behavior: stopped at a bar on the way home; short-term relief; next-day guilt and a missed gym session). Practiced urge surfing in session.
Assessment: Drinking days fell from 5 to 2, consistent with progress toward goal 1, and the client appears to be moving from preparation to action. Work stress and the route home are the main triggers. Goal 2 was not met during Friday’s reported craving episode (6/10; no coping step used); coping was practiced in session. Goal 3 is not yet met (1 of 2 meetings). Asked directly: denied tremor, sweating, hallucinations or past withdrawal seizures, and denied morning drinking; no current withdrawal symptoms reported or observed. Recent reduction warrants clarification of prior amounts, duration and time since last drink, and prompt medical assessment if withdrawal risk is suspected. Denied suicidal thoughts, plan or intent and self-harm.
Plan: Continue weekly individual sessions. Client: keep a craving log, use urge surfing when cravings reach 5/10, take a different route home on Fridays and attend 2 meetings next week. Clarify the recent drinking history and arrange prompt medical assessment if withdrawal risk is suspected. With the client’s written consent, refer to primary care to discuss medication for alcohol use disorder and send a brief summary. Client knows to seek urgent medical care for withdrawal symptoms such as shaking, sweating or confusion, and to call or text 988, or call 911 in an emergency, if thoughts of suicide arise. Next session in 1 week; review the craving log.
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Tips for SOAP Notes for Substance Use Disorders
1. Quantify use
Record the substance, number of days, amount and route since the last session, compared with the week before or intake.
2. Record cravings and triggers
Rate cravings (for example 0–10), name the trigger and note what the client did when the craving peaked.
3. Screen for withdrawal and overdose risk
Ask about withdrawal symptoms and history, and for opioids about recent abstinence and naloxone. Refer for medical assessment when needed.
4. Name the intervention
Write “motivational interviewing,” “functional analysis,” “urge surfing” or “relapse prevention planning,” not just “discussed sobriety.”
5. Use severity and stage of change
Record the DSM-5-TR severity and your view of the client’s stage of change, and how this session moved it.
6. Record consent for coordination
Before contacting a prescriber, program or family member, record the client’s written consent and what you shared, following 42 CFR Part 2 if your program is covered.
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Further Reading
- SAMHSA — Provides comprehensive resources and guidelines for treating and documenting substance use disorders.
- DSM-5-TR — Offers diagnostic criteria essential for the assessment section of SOAP notes in substance use disorder cases.
- APA Documentation Guidelines — Details best practices for clinical documentation, including SOAP notes, relevant to mental health professionals.