How to Get the SOAP Format Right

Are you considering using the SOAP format for note-taking and documentation? We created a  SOAP note template and SOAP format examples to make it easier for you to implement.

For many mental health clinicians, documentation can be a daunting and time-consuming part of their work that elicits about the same level of excitement as annual taxes. However, it’s a necessary part of the job. 

There are several reasons why templates, such as  the SOAP format template, are so useful. Note templates can serve as tools to remind clinicians about the information they need for clear, efficient, and effective record keeping. 

The SOAP note format prompts clinicians to notate what has occurred with a client and add information pertinent to other professionals, while also providing details that comply with audits and ensure insurance reimbursements.

Since the 1970s, the SOAP note has been widely recognized as a standard method of documentation throughout the healthcare industry.  

The SOAP format excels in both effectiveness and efficiency by succinctly capturing all important information.

Although the format does not make completing notes more exciting, it can make them less burdensome to clinicians. 

Given the usefulness of the SOAP format and its widespread adoption, mental health practitioners interested in simplifying their documentation should take note.

To help you understand the SOAP documentation format and utilize it correctly, we’ve provided a free SOAP note template below.

The four sections of a SOAP note

There are four main sections of the SOAP note, prompted by the acronym in its title:

S – Subjective

O – Objective

A – Assessment

P – Plan

Next, we’ll address the purpose of each of the four sections, one by one.

S – Subjective

The Subjective section of the SOAP format documentation is focused on the experiences, views, and emotions of the client from their perspective.

This includes the client’s chief complaint, presenting problems, and reported history. Relevant direct quotes from the client are also included here to effectively capture the current state of the client.

O – Objective 

The Objective section focuses on facts and observable evidence. Descriptive clinical observation and standardized assessment are the priority.

Clinicians should include mental status measures, observable behaviors, assessment results, and related clinical or medical reports here.

A – Assessment

The Assessment section of the SOAP format involves using clinical judgment and analysis to provide a combined summary of the Subjective and Objective sections. 

This is where the clinician will interpret the subjective reports of the client, the objective data, and note any determinations related to clinical themes or DSM criteria. 

If you do not have full clarity about the client’s condition, different possible diagnoses can be listed here as well. This section should include any changes with the client’s status and their response level to interventions provided.

Progress, regression, or lack of change should be noted as specifically as possible, with reference to the treatment plan.

P – Plan

The Plan section should outline specific next steps with the client that will help move them toward their goals.

This should include the interventions that will be implemented and how those interventions will move the client closer to their goals. 

Clinicians should also note any specific adjustments to the treatment plan and near-term targets. This can also include any further assessments or referrals that are necessary.

SOAP note template 

Here’s a SOAP note template that can be utilized by mental health clinicians. 

It lays out the Subjective, Objective, Assessment, and Plan sections, along with some guiding questions to help you complete each of the sections in the SOAP format. 

Subjective questions to address:

• What are the core problems the client believes they are facing?
• What symptoms and resulting life challenges did the client report?
• What history and context did the client share that would be essential to include?
• What specific statements did the client make that help illustrate their current experience?

Objective questions to address:

• What were the behaviors, nonverbal expressions, gestures, postures, and overall presentation of the client?

• What was the client’s mood and affect?
• What was the nature of the client’s thought processes, thought content, and orientation to their environment?

• How did the client respond during the session, and during particular topics of discussion?
• What assessment scores were recorded or discussed during the session?

Assessment questions to address:

• Which clinical themes are present?
• What diagnostic criteria are being met by the client?
• Are there any differential diagnoses that should be noted for further assessment?
• What interventions were utilized in session and how did the client respond?
• What progress or lack of progress has the client made towards their self-determined goals?

Plan questions to address:

• What specific steps has the client committed to work on as homework before the next session?
• What specific interventions will the clinician be focused on in the upcoming sessions?
• Will any referrals or additional recommendations be provided to the client?
• What changes were made to the treatment plan, if any?

SOAP note format examples 

SOAP format example #1

S – Subjective

Client is a 42-year-old female seeking therapy for anxiety. Client reported extreme worry that is generalized to all areas of her life. She shared that this worry has been consistently present for two years. She noted persistent muscle tension, difficulty concentrating, and difficulty staying asleep. She stated, “It is hard for me to focus at work and get my projects done because I’m always worrying about something.”

O – Objective

Client’s speech was rapid. Her thought processes were tangential at times. She appeared uncomfortable and attempted to avoid discussing her struggles at work. She was fidgety throughout the session and her body appeared tense. Mood was anxious with congruent affect. She denied any suicidal ideation, homicidal ideation, or psychosis. She was oriented x 4 (alert and aware). Her GAD-7 assessment score was 12 (moderate).

A – Assessment

Client continues to experience moderate symptoms congruent with her generalized anxiety disorder diagnosis. Her frequent rumination, worry, and difficulty concentrating is disruptive to her job performance. Her symptoms have decreased from severe to moderate through the application of mindfulness based stress reduction and cognitive behavioral therapy (CBT). She has made attempts to implement learned coping skills, but continues to have significant levels of generalized worry. Social anxiety disorder must still be ruled out given the client’s previous mention of anxiety about relationships. Clinician applied CBT to help her identify the cognitive distortions causing her worries. She was receptive to the intervention.

P – Plan

Client will work on her CBT thought record this week in order to better identify her cognitive distortions. The clinician will continue to provide empathic listening and client-centered therapy. The clinician will review and teach new mindfulness-based techniques to help with relaxation. The clinician will review the client’s CBT worksheets. The clinician will introduce thought disputation methods to help create alternative thoughts. The treatment plan goals remain unchanged.

SOAP format example #2

S – Subjective

Client continues to seek therapy for reported symptoms of traumatic stress related to complex childhood trauma. They reported ongoing intrusive symptoms of frequent nightmares and memories that disrupt their concentration. The client noted continued avoidance of seeing any members of his nuclear family. Client stated: “I know mom and dad did this to me, but it’s hard to see my siblings because they’re reminders of what happened.” They reported ongoing challenges with hypervigilance, startle response, irritability, shame, and difficulty sleeping. The client reported the symptoms have caused difficulty in their ability to work.

O – Objective

Clinician conducted the PCL-5 assessment and client scored a 43, which the clinician  reviewed with the client. Client appeared hypervigilant and uncomfortable during the session. They rarely looked at the clinician  in the eye during the session. Their mood was anxious and irritable. Their speech, thought processes, and thought content were normal. They were distractible and distant several times throughout the session. Their insight and judgment were fair. They were cooperative.

A – Assessment

The client continues to experience symptoms of PTSD. Their symptoms directly correlate with repeated experiences of emotional and physical abuse during childhood. These symptoms have been present the majority of their life. Their symptoms impair their ability to maintain family relationships and consistently hold a job. They show good insight of their past and how that affects their present life. Their symptoms have increased slightly since starting EMDR therapy, due to engagement with the traumatic memory. Clinician provided further psychoeducation on trauma and continued with the second session of EMDR Phase 4 reprocessing. Client experienced high levels of distress during the processing, but did identify some adaptive insights. Client was receptive to the interventions.

P – Plan

The clinician will continue to reinforce psychoeducation and relaxation skills that have been provided. The clinician will continue EMDR Phase 4 reprocessing in order to help the client meet their goal of reducing hypervigilance and intrusive symptoms. The GAD-7 assessment will be conducted to rule out generalized worry.

Hopefully these examples and templates make it easier for you to use the SOAP format for your note-taking and documentation. 

To learn more, check out our downloadable guide on How to Write a SOAP Note.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.

READ NEXT: 

• How to Write the SOAP Note Subjective Section

• How to Write the Objective in SOAP Notes
• How to Write the SOAP Note Assessment Section