How to Write the SOAP Note Subjective Section

September 7, 2023

A laptop sitting on a desk showing the SOAP note subjective section being drafted by a therapist

If you’re wondering what to include in the SOAP note Subjective section, you’re in the right place. This article will cover how to write the Subjective part of a SOAP note and provide examples.

The SOAP note is one of the most widely used formats of documentation across multiple sectors of healthcare. The format has helped to better standardize documentation—helping clinicians effectively provide care, track progress, report during audits, and get insurance reimbursements.

The acronym SOAP lays out the four sections of the note: Subjective, Objective, Assessment, and Plan.

Understanding how to write the Subjective part of a SOAP note and what to include in the Subjective section is an essential place to begin, in pursuit of mastering the SOAP format.

What is the Subjective part of a SOAP note?

As the first section of the SOAP note, the Subjective section starts with an emphasis on the client.

Think of it as a neutral retelling of the client’s self-report.

The Subjective section explains how the client tells their own story. Therefore, the SOAP note Subjective section is focused on the experiences, views, and emotions of the client, from their perspective.

How to write the Subjective part of a SOAP note

When considering how to write the Subjective part of a SOAP note, clinicians can view themselves as interviewers or reporters who are trying to accurately represent the client’s point of view.

At times, there may be other individuals involved in the treatment of a client, such as a parent or spouse. These individuals have permission to provide a description about the client, and that collateral information should also be included in the Subjective part of SOAP notes.

What’s included in the SOAP note Subjective section?

All of the following components are included in the Subjective section of the SOAP note.

These components do not need to be separated in the actual note, as they are below, but should be incorporated altogether in a fluid manner.

See the SOAP note Subjective examples at the end of this article for further reference.

1. Chief complaint

The chief complaint, or presenting problem, is the main reason that the client is having their therapy appointment. It is typically a concise summary statement that describes the core challenge(s) that the client is facing.

If a client reports many different issues, the clinician will want to note only the most pressing issues that also relate to the therapeutic goals of the client.

2. Reported history

This relates to the context and past history of the client’s presenting problem. It could include things like the onset and severity of their symptoms, the frequency and duration of their symptoms over time, and things that have been known triggers for the symptoms.

Any relevant medical, social, cultural or other contextual factors that are related to the symptoms should also be noted.

3. Further questioning and review of symptoms

If the client is unable to share a clear picture of their symptoms, or if differential diagnoses need to be explored, the clinician should ask follow-up questions to evoke more specific answers.

The clinician can then probe further to determine if the client is experiencing anything from the symptom list of a specific diagnosis.

Clinicians should also ask clarifying follow-up questions about duration and frequency of symptoms, as well as details of

functional impairment.

4. Direct quotes

It can be useful to mix in a quote or two from the client that helps to emphasize or further explain their experiences.

This can be a word, a short phrase, or a sentence.

This should not be an entire paragraph of dialogue, but rather small “sound bites” that help create a fuller picture of the client’s perspective.

5. Strengths and competencies

The Subjective section can also be a place where the clinician captures positive things the client sees in themselves. This could include positive attributes, coping skills, or cultural strengths.

Although insurance companies are not looking for these items, it is important for strengths-based and culturally-attuned clinicians to record these things for future reference.

6. Specificity of symptoms

One of the components that is most crucial to the SOAP note Subjective section is very specifically listing symptoms related to the client’s diagnosis.

This is highly important for later reference by clinicians, and it is imperative that it be included for insurance clients. Insurance companies, as they evaluate notes, are looking for high levels of specificity when it comes to symptoms and impairment.

They are always looking at documented “medical necessity” as the reason they should keep paying for therapy sessions. Whether you love it or hate it, this is one of the daily realities that many clinicians must deal with.

Medical necessity relates to symptoms of the diagnosis and the ways that those symptoms are specifically impairing the client’s social life, work, or ability to carry out other activities of daily living.

These descriptions should also be related to the client’s treatment plan to help ensure insurance approval.

What to avoid when writing the Subjective section of your SOAP note

There are two main things to stay away from in the Subjective part of a SOAP note.

The first is clinical judgment.

Any determinations should be suspended until reaching the Assessment section of the note.

The Subjective section is more about a neutral recording of the client’s self-reported problems.

The second thing to avoid when writing the SOAP note Subjective section is providing too many extraneous details.

For example, if the client is sharing a long story about an interpersonal conflict they experienced, it is not necessary to quote the client or mention details unless they are directly related to the client’s presenting problem, diagnosis, and treatment plan.

In this case, one could note that the “client stated they recently experienced a relational conflict which increased their anxiety symptoms, namely persistent worry and muscle tension.”

SOAP note: Subjective vs. Objective

Following the Subjective section in the SOAP note acronym is the Objective section.

Both of these portions are descriptive of the client, however, they are dissimilar in their nature.

As explained above, the Subjective section shares the experience of the client through their own emotions, thoughts, perceptions, and words.

The Objective section differs by focusing on things that can be observed, measured, and tested by the clinician.

This should include signs of the client’s mental status and emotional state.

It can include results from conducted assessments such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Elements of the Mental Status Exam are often noted in the Objective section too.

The key here is to remember that self-reported symptoms from the client are placed in the

SOAP note Subjective section, whereas observable signs and assessment results are written in the Objective section.

For example, if a client reported hyper-vigilance, startle response, and other trauma-related symptoms, that would be recorded in the Subjective section.

If the clinician witnessed a client constantly scanning their environment and getting physically startled when they heard a door close in the other room, those observable signs would be noted in the Objective section.

SOAP note Subjective examples

Example #1

Client is seeking therapy to work on their depressive symptoms.

They reported being impacted by low energy, lack of motivation, low mood, and difficulty concentrating this week. They shared that they were late to work on two days, due to difficulty with getting out of bed in the morning. Client stated, “Mornings are so hard for me, but once I‘m at work I can push through the day and be productive—despite still feeling depressed.”

They noted that their struggles with depression have impacted their work for two years.

They reported frequently experiencing cyclical depressive episodes of three weeks or longer at a time.

Example #2

Client reported still experiencing significant panic symptoms despite attempting the paced breathing exercise.

She stated that she had three panic attacks in the past two weeks.

She defined her panic attacks as involving extreme dizziness, a racing heart, rapid breathing, shaking, and numbness that begins rapidly and subsides within 20 minutes.

She added that during one of her panic attacks: “I was so afraid that I was having a heart attack and thought I was about to take my last breath.”

She noted that her persistent fears of having another panic attack caused her to avoid going out in public with her friends at any point in the past two weeks.

She reported that what helps her feel the most calm is speaking with her mother and participating in her indigenous spiritual practices.

Hopefully this article on everything that goes into the SOAP note Subjective section provides the examples and information to ensure you are confident that you understand how to write the Subjective part of a soap note.

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