SOAP note examples: 5 sample notes for clinicians

A SOAP note gives you a structured way to document each session. This guide explains the SOAP note format and walks through five sample notes: four for therapy and one for occupational therapy. Use these SOAP note examples to check your own documentation or adapt them for your specialty.

All client details below are fictional and written for educational purposes. They don't represent real clients, clinicians, or clinical events.

What is a SOAP note?

SOAP stands for Subjective, Objective, Assessment, and Plan. Dr. Lawrence Weed introduced the format as part of his problem-oriented medical record, which he first published in 1964 and brought to wide attention with a 1968 paper in the New England Journal of Medicine. Clinicians across healthcare now use it, including SOAP notes for occupational therapy, physical therapy, medicine, and pharmacy.

SOAP notes for therapy give you an organized place to record clinical analysis. They also create a shared language with collaborating providers and a consistent record for later referrers. A well-written note supports payer documentation requirements too. Reviewing SOAP note examples is one of the fastest ways to see how those goals play out in a real note.

How do you write a SOAP note?

Knowing how to write a SOAP note starts with knowing what each section captures. Review the SOAP note format below, then compare it with the SOAP note examples that follow.

Subjective: the client's perspective

This section holds the client's experiences, views, and emotions. Include the chief complaint, the presenting problem, and relevant history. Add direct client quotes when they capture the client's current state in their own words.

Objective: observable facts

Record what you observe and measure. That includes mental status observations, behavior, standardized assessment results, and any risk assessment. Keep interpretation out of this section.

Assessment: your clinical judgment

The Assessment connects the Subjective and Objective sections to your clinical interpretation. A strong SOAP note assessment example doesn't recap the first two sections. It synthesizes them, noting themes, diagnostic considerations, and what the session revealed about the client.

Plan: next steps

List the specific steps that move the client toward their goals. Include any treatment plan adjustments, near-term targets, and a summary of progress toward objectives.

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What do SOAP note examples look like?

These five SOAP note examples use the same four-section structure across different presentations. Each of the SOAP note examples starts with a short description of what it demonstrates. Use each sample SOAP note as a benchmark, not a script.

Example 1: Generalized anxiety disorder

This therapy SOAP note example shows how to capture subjective distress, observable behavior, and a standardized score from the Generalized Anxiety Disorder 7-item scale (GAD-7).

Subjective: Client reported ongoing worry and anticipatory anxiety. They stated, "It's hard for me to get excited to go anywhere because I'm always expecting the worst." They also reported restlessness, muscle tension, and three to four hours of sleep per night.

Objective: Client's speech was rapid and rambling, and their thought process was tangential. Writer reviewed the anxiety cycle, and client engaged briefly before changing the subject. Client was fidgety throughout. Mood was anxious with congruent affect. Client denied suicidal ideation (SI), homicidal ideation (HI), and psychosis. They were oriented to person, place, time, and situation. Writer administered the GAD-7 and reviewed the score of 18, which is in the severe range.

Assessment: Client's symptoms remain severe and consistent with their generalized anxiety disorder diagnosis. Rumination, hypervigilance, physical tension, and worry disrupt their self-care, social life, and work. Writer will continue to assess for social anxiety disorder given client's earlier mention of anxiety-related relationship difficulties.

Plan: Client has tried a few coping skills but has not completed agreed-upon homework and tends to avoid deeper work. Writer will continue building rapport and trust, provide anxiety psychoeducation, and teach mindfulness-based relaxation techniques. Writer will introduce the cognitive-behavioral therapy (CBT) model next session.

Example 2: Major depressive disorder

This therapy SOAP note example covers a telehealth session. It shows how to document location, physical presentation on video, and passive suicidal ideation with a risk judgment.

Subjective: Client reported low mood, low motivation, loss of interest, social isolation, guilt, shame, loss of appetite, and trouble concentrating for the past seven months. She stated, "I've never felt this sad before. I can't get myself motivated to do anything I used to do."

Objective: Session was held by video, and client was at home (address on file). She was disheveled and attended the session lying in bed. Her speech was slow and halting. Attention and concentration were within normal limits. She was forthcoming and showed reasonable insight. She denied HI and psychosis. She reported passive SI last week but denied current SI, plan, or intent. Client named her sister and her dog as reasons for living. Writer assessed current risk as low. Writer reviewed safety steps, including calling or texting 988 or calling 911 if thoughts intensify, and client acknowledged them.

Assessment: Client's symptoms are consistent with a major depressive episode and meet the duration criterion. Her physical health and relationships are significantly affected, and her mood and activity levels have declined in recent weeks. She reported no history of manic symptoms, so bipolar disorder is not suggested at this time. Writer will continue to assess functional impairment and differential diagnoses.

Plan: Client will benefit from behavioral activation. Writer will provide psychoeducation on major depressive disorder, CBT, and behavioral activation, then develop an initial weekly activity plan with client. Writer will reassess SI at each session.

Example 3: Acute stress disorder

This therapy SOAP note example follows a client three weeks after a car accident. It shows how to document trauma symptoms, a Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) score, and consent for treatment.

Subjective: Client continues therapy for acute stress after a car accident three weeks ago. He reported nightmares, flashbacks, and distress at reminders of the event. He avoids driving and road travel. He stated, "I haven't driven since the accident. I don't know if I ever will." He also reported hypervigilance, low mood, poor sleep, startle response, irritability, social isolation, self-blame, and difficulty imagining a positive future. He said symptoms have strained his relationship with his partner.

Objective: Writer administered the PCL-5 and reviewed the score of 49 with client. Client appeared uneasy and hypervigilant. He shifted often in his chair, picked at his nails, and looked out the window. Mood was anxious with congruent affect. Speech, thought process, and thought content were normal. Insight and judgment were fair. Client was cooperative but guarded when discussing the accident.

Assessment: Client's symptoms began immediately after the accident, were not present before it, and now affect his relationship and daily travel. He is within the three-day-to-one-month window for acute stress disorder. If symptoms persist beyond one month, Writer will evaluate for posttraumatic stress disorder (PTSD). Client shows good insight and is receptive to treatment.

Plan: Client has started using stabilization skills despite frustration with ongoing symptoms. Writer and client discussed trauma-focused treatment options, and Writer explained the risks and benefits of the approach. Client gave verbal consent to begin. Writer will start the preparation phase while continuing to assess client's stability and capacity to tolerate difficult emotions.

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Example 4: Adjustment disorder

This therapy SOAP note example doubles as a SOAP note assessment example, showing how to distinguish adjustment disorder from major depressive disorder. It also documents a mild score on the Patient Health Questionnaire-9 (PHQ-9) in context.

Subjective: Client reported stress and difficulty adjusting after voluntarily leaving a 12-year career six weeks ago to pursue a new path. She described self-doubt, loss of identity, and uncertainty about the future. She stated, "I spent 12 years in that career and now I don't really know who I am without it." She also reported mild sleep disruption, trouble concentrating, reduced appetite, and irritability with her spouse. She has no history of mental health treatment and described her mood before the change as stable.

Objective: Client was well-groomed, made consistent eye contact, and was engaged throughout. Speech was clear, and thought process was linear and goal-directed. She was occasionally tearful when discussing her identity but composed herself quickly. Mood was mildly low with congruent affect. Insight and judgment were good. She denied SI, HI, psychosis, and history of mania. Writer administered the PHQ-9 and reviewed the score of 8, which is in the mild range.

Assessment: Client's symptoms are consistent with adjustment disorder with depressed mood. They began within three months of the career change and were not present before it. Client does not currently meet full criteria for major depressive disorder. Writer will monitor for worsening depressive symptoms. Strong self-awareness and motivation are favorable indicators.

Plan: Writer will introduce values clarification exercises to help client reconnect with a stable sense of self beyond her career. Writer will provide psychoeducation on common challenges in major life transitions. Writer and client will set short-term goals together. Client agreed to keep a brief daily journal to track her mood and moments of confidence.

Example 5: Occupational therapy SOAP note

For clinicians who write SOAP notes for occupational therapy, this occupational therapy SOAP note example shows functional testing, strength measurements, compensatory movement patterns, and coordination with a physician.

Subjective: Client, a 45-year-old administrative assistant, attended her weekly session after a right wrist fracture six weeks ago. She stated, "I can do some things around the house now, but anything that needs grip or pinching still frustrates me." She reported difficulty with dressing, meal preparation, typing, and handwriting. She cannot yet return to work, which has contributed to low mood and a loss of routine.

Objective: Client was alert, cooperative, and motivated. Writer administered the Jebsen-Taylor Hand Function Test. Client showed reduced speed and accuracy on fine motor subtasks with her right dominant hand compared with normative values. Grip strength was 14 pounds on the right and 52 pounds on the left. During simulated work tasks, client substituted lateral pinch while writing. Right wrist extension remains limited. Affect was pleasant but mildly frustrated during harder tasks.

Assessment: Client has deficits in fine motor coordination, grip strength, and wrist range of motion consistent with post-fracture recovery. These deficits limit instrumental activities of daily living (IADLs) and work tasks. Compensatory patterns raise the risk of overuse injury if not addressed. Client shows gradual, measurable progress toward baseline, and skilled occupational therapy remains necessary.

Plan: Writer will continue progressive strengthening, fine motor retraining, and work simulation. Client will complete a daily home exercise program targeting wrist extension and pinch strength. Writer and client agreed to add a 15-minute typing simulation to upcoming sessions. Writer will contact client's physician about range of motion limits to determine whether further imaging or consultation is needed. Progress will be reassessed in two weeks with standardized outcome measures.

What SOAP note mistakes should you avoid?

Even strong therapy SOAP notes can slip in a few predictable ways. Comparing your notes with the SOAP note examples above can reveal gaps. Watch for these common SOAP note mistakes:

• Vague wording: Replace "discussed relationship issues" with the specific issues and how the client felt.

• Unsupported impressions: Back up observations with evidence, such as "appeared anxious, wringing hands and speaking quickly."

• Assessments that recap: Synthesize the Subjective and Objective sections instead of repeating them.

• Missing in-session work: Record what you did in the session and how the client responded, not only what you plan next.

• Missing session details: Check payer and state requirements for items like date, start and stop times, and place of service.

SOAP note FAQs

What does SOAP stand for?

SOAP stands for Subjective, Objective, Assessment, and Plan. Each section captures a different layer of the session: the client's report, your observations, your clinical interpretation, and your next steps.

Is a SOAP note a progress note?

Yes. A SOAP note is a format for writing a progress note, not a separate document. SOAP notes for therapy organize the session record into four sections, which makes your clinical reasoning easier to follow and share.

Do SOAP notes need to follow HIPAA?

Yes. SOAP notes kept in the client's record contain protected health information, so store and share them in line with HIPAA. They are different from psychotherapy notes. HIPAA defines psychotherapy notes as a mental health professional's notes analyzing a session that are kept separate from the rest of the record. Those notes exclude items such as diagnosis, treatment plan, symptoms, and progress to date, which SOAP notes include. State laws may add stricter rules, so check yours.

How long should a SOAP note be?

There is no universal length. Include what's relevant to the presenting problem and treatment goals, and skip repetition across sections. Each therapy SOAP note example above shows a realistic length for its presentation.

How can SimplePractice help with SOAP notes?

SimplePractice includes customizable progress note templates, so you can build therapy SOAP notes into your workflow instead of starting from a blank page or searching for SOAP note examples between sessions. Note Taker, SimplePractice's AI tool, can draft progress notes from your appointments for you to review and edit before signing. For more formats and tips, read our guide on how to write a SOAP note, which includes more SOAP note examples for social workers and speech-language pathologists.

Try SimplePractice free for 30 days.

Sources

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

• Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine.

• National Center for PTSD. (n.d.). Acute stress disorder. U.S. Department of Veterans Affairs.

• National Center for PTSD. (n.d.). PTSD Checklist for DSM-5 (PCL-5). U.S. Department of Veterans Affairs.

• Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine.

• Substance Abuse and Mental Health Services Administration. (n.d.). 988 frequently asked questions.

• U.S. Department of Health and Human Services. (2017). Does HIPAA provide extra protections for mental health information compared with other health information?

• Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine.

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