How to Write Social Work SOAP Notes

Wondering about social work SOAP notes and why they’re important for your practice? This article shows how to create SOAP notes for social workers.

Whether you’re interviewing a client at your office or making a home visit, as a social worker, it’s essential to capture and keep progress  notes. 

Progress notes can help you understand your clients better, improve the quality of care, and, from a legal perspective, they can provide documentation and evidence of your sessions and treatment plans.  

One highly valuable documentation approach is the SOAP note format. In this article, we’ll take a look at the importance of social work SOAP notes and how to create one. 

What are SOAP notes for social workers? 

SOAP notes are well-structured mental health progress notes documenting that a therapy session took place. 

The acronym SOAP stands for: Subjective, Objective, Assessment, and Plan. 

Many social workers and other mental health professionals find SOAP notes useful, especially for documenting subjective information (the client’s experience of the problem). 

No matter the type of social work you specialize in—child welfare, family, school, community, etc.—the social work SOAP notes format works well. 

As a clinical social worker with a private therapy practice, the style of SOAP notes for mental health that you use should reflect the work you do. 

SOAP notes for social workers focused on case management where they help clients navigate the system will be different. 

While formats may vary from one field to another, and even workplaces or departments, all SOAP notes should be  professionally written, unbiased, factual, and up-to-date.  

Understanding the SOAP process in social work 

In this section, we’re going to dive into each part of social work SOAP notes  and what they entail. 

Timing is key when writing your progress notes, so try to complete them within 24 hours after each session with a  client, preferably immediately following the session while details are still fresh in your memory. 

S – Subjective 

The Subjective section of SOAP notes for social workers focuses on the client’s description of their problem. 

It includes the questions you ask them and their response enclosed in quotes. Using their own words will help paint an accurate picture of their emotional state. 

Subjective information to add to this part can include:

• Your client’s chief complaint
• Past history
• Symptoms
• Coping skills they’re currently using
• Environment

Example: When asked about how he feels most days, Tom stated, “I feel empty. Maybe it’s all my fault.” 

Some clients have trouble expressing how they feel, which is why it’s important to ask clarifying questions. This will allow you to add more relevant information, while also preventing you from making assumptions about their condition. 

O – Objective

The Objective part of SOAP notes focuses on facts. In other words, this section includes  observable and measurable data. You can include signs you’ve noticed from your client—such as crying and nail-biting, in the case of someone experiencing anxiety. 

Other factual information to write in the Objective section includes: 

• Mental status examination (MSE) observations, which look into the client’s appearance, behavior, and speech, among other things
• Medical findings and diagnostic reports provided by their healthcare professionals
• Results from psychological tests

Example: The client maintained a slumped posture throughout the session. His fists were clenched while talking about a childhood memory. 

Always base these notes on facts. Steer clear of making judgments based on personal interpretations, and even using negative labels, such as weak, stubborn, rebellious, or impatient. 

A – Assessment

For the Assessment part of SOAP notes, a social worker combines subjective and objective data from the previous sections. By noticing patterns, you can come up with a diagnosis (or list of probable diagnoses) and a well-rounded plan for treating the client. 

Your role here is to use your best clinical judgment based on what you already know about your client. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) may also serve as a helpful reference to define the client’s experience.

Example: Based on the client’s history, self-report, and behaviors during the session, he is manifesting signs and symptoms of post-traumatic stress disorder (PTSD). 

P – Plan 

As the term implies, the Plan section of social work SOAP notes outlines the treatment plan for the client. 

Write down short-term and long-term goals that you and your client have mutually agreed to and other implementation steps. 

Here are other things you can include: 

• Homework assignments, such as completing therapy worksheets and practicing coping strategies 
• Referrals made to other medical or mental health professionals 
• Follow-up appointments
• Interventions that are and aren’t working

Example: Refer the client to a speech therapist this week to improve verbal communication skills. For our next session, we will focus on labeling emotions. 

Be careful to avoid setting unrealistic goals and deciding what’s important for the client without discussing it with them. 

Why are social work SOAP notes important?

Writing social work SOAP notes between sessions may be the last thing on your mind during a hectic day, however keeping proper documentation can have significant benefits for your practice. 

Benefits of completing social work SOAP notes include:

• You’ll have a clear picture of your client’s progress from their first therapy session, which helps you measure the effectiveness of your approach. 
• SOAP notes keep you on track if a client brings up a topic that was discussed during the previous session. 
• For case management, SOAP notes serve as a means of communication with other professionals who are involved in your client’s case. 
• SOAP notes provide insurance companies with evidence to verify the insurance claims you submit. Insurance companies are more likely to reimburse claims if they’re supported by progress notes. 
• SOAP notes for social workers can provide legal protection in cases where a lawsuit is filed. For example, SOAP notes show the steps you took to safeguard a client who posed a risk to themselves and others. 

SOAP note examples for social workers 

If you’re a private practice social worker looking to adopt the SOAP note format, here’s an example to familiarize yourself with the process: 

Subjective 

When asked about his adherence to the treatment plan, the client stated, “I’m dealing with my panic attacks by breathing in and breathing out slowly, and I think it’s helping. Sometimes I miss a day or two of taking my anxiety meds, but that’s okay. I take them as soon as I remember.” 

Objective 

The client responds to questions in an even-paced manner and smiles when talking about the improvement of his symptoms. He maintained a relaxed posture throughout the session, with his back leaned backward in the chair and hands on his lap, without any signs of clenching. 

Assessment 

The client’s presentation and self-report of decreasing anxiety symptoms suggest recovery and a willingness to practice coping skills. 

Plan

Continue psychotherapy with the client on Wednesdays at 2:00 p.m. The Client will also continue using CBT coping skills, such as diaphragmatic breathing and challenging negative thoughts. To further reduce anxiety symptoms, the client agrees to incorporate daily exercise, such as a 15-minute walk, and using an alarm to remind him to take his medications. 

Tips for writing social work SOAP notes

SOAP notes for mental health may differ from one social worker to another depending on the type of work they do, where they work, and the amount of client information available. 

Regardless, keep these tips in mind: 

• Stick to the same format for each client. Don’t jump from one format to another, such as using the SOAP method for one session and a different framework in the next session. 
• Use a professional, but easy to understand tone when writing SOAP notes.
• When filling out the Subjective section of your SOAP notes, consider preparing a list of questions—incorporating how, what, when, where, and why—to draw out relevant information from your client. 
• Update your SOAP notes regularly to accurately capture changes in your client’s condition and treatment plan. 

As a final note, make sure to keep your social work SOAP notes in a reliable storage system—such as your electronic health record (EHR)—for confidentiality and to prevent losing any information. 

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 a SOAP Note with Examples