How to Write the Objective in SOAP Notes

September 22, 2023

A clinician sits down with her notebook to try writing the Objective in SOAP notes she has to complete.

In this article, we’ll cover how to write the Objective, in SOAP notes. The O in SOAP stands for the Objective SOAP note section.

In full, the SOAP acronym stands for: Subjective, Objective, Assessment, Plan. Each section notates the necessary aspects of a clinicians’ documentation of their clients’ sessions and ongoing treatment.

The SOAP note format has helped to better standardize documentation. The SOAP note is one of the most widely used formats of documentation across multiple sectors of healthcare.
By using the SOAP note format, clinicians can effectively and efficiently record information collected, communicate with collaborating providers, ensure reimbursement from insurance payers, and remain in compliance with clinical regulations.

Keep reading to learn how to write the Objective in SOAP notes, so you can master all aspects of writing a SOAP note.

What is the Objective part of SOAP notes?

The O, or Objective SOAP note portion, is all about the facts. It follows the S, or Subjective part of a SOAP note.

This second section of the SOAP note is focused on empirical and observable evidence. Clinicians should try to be as unbiased as possible. Descriptive clinical observation and standardized assessment are the priority.

When considering how to write the Objective part of a SOAP note, the clinician can view themself as a scientist reporting impartial discoveries about the client.

These measurements can help display the client’s progress or lack of progress toward their goals. Observable signs, mental status measures, assessment results, and related clinical or medical reports are what the clinician should have in mind here.

What goes in the Objective part of a SOAP note?

Observable signs

Observable signs encompass the observations clinicians make of their clients during sessions.

They serve to further illustrate the symptoms described by the client in the Subjective section of a SOAP note.

For a client with anxiety, for example, signs could include fidgeting and tapping their feet. For the client with PTSD, it could be their startle response when they hear the sound of their text message notification.

Mental status measures

The Mental Status Exam, or observations of a client’s mental state, offers some helpful categories that can be included in the Objective SOAP note section.

This examination describes items such as the client’s:

Orientation to time and place
Appearance
Behavior
Speech and motor activity
Mood and affect
Thought processes and content
Attitude and insight
Concentration and attention
Memory capacity
Other cognitive abilities

While it is not mandatory to conduct a full Mental Status Exam every session, it can be helpful to report some of the therapy session’s notable items from these categories.

When making these observations, it is important that the clinician attempts to be as objective as possible and be mindful of any of their own biases that may arise.

There may be other things behind a client’s presentation that the clinician doesn’t fully understand. If the clinician is not confident they understand why a client is responding a certain way, it is helpful to ask more clarifying questions.

Before writing a client off as “resistant,” “aggressive,” “unresponsive,” or any other negative observations, it is important that the clinician rule out any physiological, cultural, circumstantial, or other factors that could be at play.

Assessment results

Some examples of widely used assessments of symptoms include:

Patient Health Questionnaire-9 (PHQ-9) to measure signs of depression
General Anxiety Disorder-7 (GAD-7)
PTSD Checklist for DSM-5 (PCL-5)

Clinicians can use these at different points throughout treatment to help track the client’s progress in therapy.

These standardized assessments can help provide more data to determine the client’s progress over time.

These quantitative results should be part of your reporting of the Objective in SOAP notes.

Clinical or medical reports

Any formal reports about the client from medical doctors or other healthcare professionals can also be helpful and informative pieces of the Objective in SOAP notes..

The client may have a report from a recent psychological test, a note from a psychiatrist about a change in psychotropic medication, or a summary of medical treatment for a condition that is related to the client’s mental well-being.

Any information like this is considered Objective in SOAP notes and should be included in this section.

Subjective vs. Objective sections of SOAP notes

The section preceding the Objective section in the SOAP note is the Subjective section. Both of these portions are descriptive of the client, however, they are dissimilar by nature.

As explained above, the Objective SOAP note section focuses on things that can be observed, measured, and tested by the clinician.

The Subjective section, on the other hand, shares the experience of the client through their own emotions, thoughts, perceptions, and words. It is the client’s self-report.

The Subjective section would include things like the client’s chief complaint, reported history, and descriptions or quotes about their own symptoms. It can also include anything the client says about their own strengths, competencies, and improvements.

The key here is to remember that self-reported symptoms from the client are placed in the SOAP note Subjective section, while observable signs and assessment results are written in the Objective section.

For example, if a client reported shame, fatigue, and other depressive symptoms, that would be recorded in the Subjective section.

If the clinician witnessed the client’s slumping posture and struggling to stay awake during the session, those observable signs would be noted in the Objective section.

SOAP note Objective examples

Example #1

Client’s speech was rapid. His thought processes were tangential throughout the session, as he jumped from topic to topic.

He appeared energetic and restless. Twice during the session, he paced around the room and looked out the window.

Mood was euphoric with congruent affect.

He denied any suicidal ideation (SI)/homicidal ideation (HI) or psychosis.

He was oriented to place but was unaware of the current day of the week.

His MDQ assessment score was a 10, indicating likely bipolar disorder. Writer reviewed the report from a psychological test conducted by psychologist Dr. Ingrid West on 7/17 this year. That report included a formal diagnosis of bipolar I.

Example #2

Therapist conducted the GAD-7 assessment and the client scored a 4, which the therapist reviewed with the client. This indicates the client’s anxiety is limited to social settings and not generalized to other areas of their life.

Client joined the telehealth appointment and again refused to have their video turned on. Therapist could not visually see the client as a result.

Their voice was normal but became shaky when discussing a recent social setting where they experienced high distress.

Their mood was anxious. Their thought processes and thought content were normal.

They denied any SI or HI.

Their attention was within normal limits. Their insight and judgment were good. Their memory was intact.

The Objective section in SOAP notes is a key part of the SOAP note format. Having a grasp on this Objective lens will lead to improved documentation and hopefully to even higher quality clinical work for the clients being served.

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