Best SOAP Note Templates and Examples for Therapists and Clinicians (2026 Guide)
SOAP notes give clinicians a structured way to document sessions, track progress, and communicate across care teams. This guide covers what each SOAP section should include, how the format changes across specialties, and free SOAP note examples for anxiety, PTSD, social anxiety, OCD, bipolar disorder, and more. It also covers how an AI medical scribe can automate the writing.
What Is a SOAP Note?
A SOAP note is a progress note format that organizes a clinical encounter into four sections:
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Subjective (S): what the patient or client reports
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Objective (O): what the clinician observes and measures
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Assessment (A): the clinician's diagnosis or clinical analysis
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Plan (P): the next steps and interventions
Subjective (S): what the patient or client reports
Objective (O): what the clinician observes and measures
Assessment (A): the clinician's diagnosis or clinical analysis
Plan (P): the next steps and interventions
Copyable SOAP Note Template
Adjust this template to your setting, license type, and payer requirements.
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Client:
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Date of service:
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Session start/end time:
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Location/modality: (clinic, telehealth, home visit)
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Diagnosis/diagnostic codes:
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S – Subjective: Client's own words, concerns, and progress since the last session.
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O – Objective: Appearance, affect, behavior, engagement, and screening scores.
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A – Assessment: Clinical interpretation, progress toward goals, and emerging concerns.
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P – Plan: Interventions, homework, referrals, and next appointment.
Client:
Date of service:
Session start/end time:
Location/modality: (clinic, telehealth, home visit)
Diagnosis/diagnostic codes:
S – Subjective: Client's own words, concerns, and progress since the last session.
O – Objective: Appearance, affect, behavior, engagement, and screening scores.
A – Assessment: Clinical interpretation, progress toward goals, and emerging concerns.
P – Plan: Interventions, homework, referrals, and next appointment.
SOAP Note Components ExplainedSubjective
This section captures the patient's own words about their symptoms, concerns, and history. Document what they share about their current condition, their reasons for seeking therapy, and any emotional or physical issues. For example, a patient may describe feelings of anxiety or triggers they've noticed.
Objective
The Objective section holds your professional observations of the patient's physical appearance, body language, and other notable details. This can include nonverbal cues such as changes in posture, facial expressions, or visible signs of discomfort.
What to Do When Objective Information Is Limited
Report every observed detail, even minor ones. Strategies include:
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Record observations: Note physical cues even if they match previous findings. Consistency is valuable data.
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Acknowledge stability: If nothing has changed, say so. Phrases like "No new symptoms observed" inform the ongoing picture.
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Keep language precise: A statement such as "Patient's condition remains unchanged" is enough.
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Use tools: Measurements, vital signs, and diagnostic tools strengthen your observations.
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Consult colleagues: Peer input can corroborate what you observed.
Record observations: Note physical cues even if they match previous findings. Consistency is valuable data.
Acknowledge stability: If nothing has changed, say so. Phrases like "No new symptoms observed" inform the ongoing picture.
Keep language precise: A statement such as "Patient's condition remains unchanged" is enough.
Use tools: Measurements, vital signs, and diagnostic tools strengthen your observations.
Consult colleagues: Peer input can corroborate what you observed.
Assessment
Here you synthesize the subjective and objective data into a diagnosis or preliminary analysis that guides the therapeutic approach.
Plan
Document the next steps and interventions needed to meet the patient's goals. This may include treatment plans, follow-up sessions, referrals, or self-care activities. The plan should be actionable and tailored to the individual.
Choosing the Right Tense
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Subjective and Objective: past tense (e.g., "The patient reported having a headache"; "The examination revealed swelling in the left ankle").
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Assessment: present tense (e.g., "The diagnosis is consistent with viral infection").
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Plan: present or future tense (e.g., "The patient will start on a course of antibiotics").
Subjective and Objective: past tense (e.g., "The patient reported having a headache"; "The examination revealed swelling in the left ankle").
Assessment: present tense (e.g., "The diagnosis is consistent with viral infection").
Plan: present or future tense (e.g., "The patient will start on a course of antibiotics").
Keep tense consistent within each section.
SOAP Note Examples for Counselors and Therapists
The examples below are fictional, not real sessions.
Example: Counseling SOAP Note (Work Stress)
Subjective: The client expresses feeling "stressed and overwhelmed" by their workload. They mention struggling to "meet deadlines" and feeling "anxious about letting others down" at work. The client also reports trouble focusing and occasional panic attacks related to work pressures.Objective: The client appeared fatigued, with slouched posture and noticeable bags under their eyes. Speech was slightly rapid when discussing work stressors. The client completed the Generalized Anxiety Disorder 7-item (GAD-7) scale and scored 14, suggesting moderate anxiety.Assessment: Symptoms align with Generalized Anxiety Disorder, largely focused on workplace stress. There is evidence of negative thinking patterns and exaggerated fears about job performance. Poor sleep may be worsening the anxiety.Plan:
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Implement cognitive-behavioral techniques to counteract negative and unrealistic thoughts.
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Introduce progressive muscle relaxation exercises.
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Assign a thought journal to track anxious thoughts about work.
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Plan time management strategies for handling work tasks.
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Consider a psychiatric evaluation if symptoms do not improve or escalate.
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Schedule a follow-up in one week to assess progress and continue CBT techniques.
Implement cognitive-behavioral techniques to counteract negative and unrealistic thoughts.
Introduce progressive muscle relaxation exercises.
Assign a thought journal to track anxious thoughts about work.
Plan time management strategies for handling work tasks.
Consider a psychiatric evaluation if symptoms do not improve or escalate.
Schedule a follow-up in one week to assess progress and continue CBT techniques.
Example: Child Therapy SOAP Note
Subjective: The child shared concerns about school, showed hesitation around specific activities, and expressed fear during peer interactions. They also reported frequent nightmares, illustrating underlying anxiety.Objective: The child played alone and engaged minimally with available toys. Fidgeting and avoiding eye contact were evident, particularly when school was mentioned.Assessment: Indicators point to significant anxiety in social settings and at school. The nightmares and withdrawal from peers align with these concerns and suggest an impact on the child's social growth and daily life.Plan: Encourage the child to communicate emotions through play. Introduce social skill development in a supportive setting, along with relaxation methods such as deep breathing. Plan a follow-up to evaluate progress and refine strategies.
Example: Art Therapy SOAP Note
Subjective: The client reported sadness and frustration over the past week, describing it as "overwhelming." They noted that art activities have helped them express and manage these emotions.Objective: The client worked with watercolors and chose to create abstract shapes. They stayed calm and focused, and their body language showed active involvement.Assessment: The choice of watercolors and abstract shapes suggests a preference for non-verbal emotional expression. The client's focus and calm presence suggest art therapy is supporting emotional regulation and coping.Plan: Continue offering a variety of art materials and techniques so the client can find the most effective modes of expression. Introduce structured art exercises aimed at specific emotional issues.
Example: Couples Therapy SOAP Note
Subjective: Both partners said they feel emotionally distant. They cited frequent disagreements over financial management and household duties. One partner feels burdened and unsupported; the other expressed anxiety about financial stability and feelings of neglect.Objective: Body language was tense and voices were raised. One partner often averted their gaze, while the other showed anxiety through nervous movements and fast speech. An initial survey showed moderate dissatisfaction with the relationship on established scales.Assessment: The partners are under significant relationship stress, primarily from ineffective communication and unresolved financial issues. Their behavior and expressed emotions suggest difficulty articulating individual needs, contributing to a cycle of conflict.Plan:
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Weekly sessions: Focus on communication skills and financial concerns.
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Homework: Create a joint budget and schedule a mid-week check-in.
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Communication strategy: Introduce "I" statements.
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Progress review: Reassess after four sessions and adjust goals as needed.
Weekly sessions: Focus on communication skills and financial concerns.
Homework: Create a joint budget and schedule a mid-week check-in.
Communication strategy: Introduce "I" statements.
Progress review: Reassess after four sessions and adjust goals as needed.
Example: Emergency Room SOAP Note (Suicidal Crisis)
Subjective: The individual was taken to the emergency room by authorities due to expressed intentions of self-harm. They stated feeling overwhelmed and wanting to end their life.Objective: The individual was visibly distressed, agitated, and crying. Vital signs were within normal ranges. Physical examination showed minor lacerations on the arms. The individual openly discussed suicidal thoughts and a detailed plan to overdose on medications.Assessment: This is an immediate suicidal crisis. The diagnosis is Major Depressive Disorder with a severe current episode, posing significant risk of self-injury.Plan: Immediate psychiatric hospitalization is recommended for safety and stabilization. Perform a comprehensive risk assessment. Develop a collaborative safety plan with the individual and their family. Arrange follow-up outpatient treatment after discharge.
Detailed SOAP Note Examples by Diagnosis
Each case below is fictional.
1. Generalized Anxiety Disorder (GAD)
SUBJECTIVE
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Chief complaint: Excessive worry about daily life, feeling on edge, and constant fear of something bad happening.
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Quote: "I'm always thinking about what could go wrong, even when there's no reason."
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Impairments and challenges: Impaired concentration and sleep from constant worry, causing significant stress at work and in personal life.
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Quote: "I can't focus at work, and I wake up in the middle of the night thinking about everything."
Chief complaint: Excessive worry about daily life, feeling on edge, and constant fear of something bad happening.
Quote: "I'm always thinking about what could go wrong, even when there's no reason."
Impairments and challenges: Impaired concentration and sleep from constant worry, causing significant stress at work and in personal life.
Quote: "I can't focus at work, and I wake up in the middle of the night thinking about everything."
Symptom 1: Excessive worry
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Description: Excessive worry about a variety of life situations, lasting most of the day.
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Onset: Gradual, no specific onset provided.
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Frequency: Daily.
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Ascendance: Worsens during stressful periods.
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Intensity: Moderate to severe.
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Duration: Several years per client report.
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Quote: "I just can't stop thinking about what might go wrong."
Description: Excessive worry about a variety of life situations, lasting most of the day.
Onset: Gradual, no specific onset provided.
Frequency: Daily.
Ascendance: Worsens during stressful periods.
Intensity: Moderate to severe.
Duration: Several years per client report.
Quote: "I just can't stop thinking about what might go wrong."
Symptom 2: Difficulty relaxing
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Description: Difficulty relaxing and staying calm.
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Onset: Ongoing.
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Frequency: Daily.
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Ascendance: Stable, but worsens during stressful events.
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Intensity: Moderate.
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Duration: Several months per client report.
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Quote: "It feels like there's always a weight on me."
Description: Difficulty relaxing and staying calm.
Onset: Ongoing.
Frequency: Daily.
Ascendance: Stable, but worsens during stressful events.
Intensity: Moderate.
Duration: Several months per client report.
Quote: "It feels like there's always a weight on me."
OBJECTIVE
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Assessment tool: Clinical interview.
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Results: Evidence of chronic worry, physical anxiety symptoms (restlessness, muscle tension), and impaired concentration.
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Status: Ongoing.
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Risk assessment: No immediate risks identified.
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Approach: Cognitive-behavioral therapy (CBT) focused on worry management.
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Interventions: Validated feelings of anxiety; taught relaxation techniques and progressive muscle relaxation; assigned thought record exercises to identify worry triggers.
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Rationale: Reduce the frequency and intensity of worry through cognitive restructuring and relaxation training.
Assessment tool: Clinical interview.
Results: Evidence of chronic worry, physical anxiety symptoms (restlessness, muscle tension), and impaired concentration.
Status: Ongoing.
Risk assessment: No immediate risks identified.
Approach: Cognitive-behavioral therapy (CBT) focused on worry management.
Interventions: Validated feelings of anxiety; taught relaxation techniques and progressive muscle relaxation; assigned thought record exercises to identify worry triggers.
Rationale: Reduce the frequency and intensity of worry through cognitive restructuring and relaxation training.
ASSESSMENT
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Response to treatment: Moderate engagement, but inconsistent application of coping skills.
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Example: Client used relaxation techniques in the evening with limited success.
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Quote: "I try the breathing exercises, but I still feel tense."
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Challenges: Difficulty breaking the worry cycle and engaging in self-care.
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Therapist observations: Gradual progress, but deep-seated anxiety remains. More focus on cognitive restructuring is needed.
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Therapeutic alliance: Somewhat open to therapy, but frustrated with the slow pace.
Response to treatment: Moderate engagement, but inconsistent application of coping skills.
Example: Client used relaxation techniques in the evening with limited success.
Quote: "I try the breathing exercises, but I still feel tense."
Challenges: Difficulty breaking the worry cycle and engaging in self-care.
Therapist observations: Gradual progress, but deep-seated anxiety remains. More focus on cognitive restructuring is needed.
Therapeutic alliance: Somewhat open to therapy, but frustrated with the slow pace.
PLAN
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Homework: Continue thought records and relaxation techniques; introduce cognitive reframing exercises.
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Next session: Review the new coping strategies and refine relaxation skills.
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Continued treatment: Weekly therapy focused on challenging negative thinking patterns and reinforcing coping strategies.
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Coordination of care: None at this time.
Homework: Continue thought records and relaxation techniques; introduce cognitive reframing exercises.
Next session: Review the new coping strategies and refine relaxation skills.
Continued treatment: Weekly therapy focused on challenging negative thinking patterns and reinforcing coping strategies.
Coordination of care: None at this time.
2. PTSD Following Trauma
SUBJECTIVE
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Chief complaint: Recurring flashbacks, nightmares, and hypervigilance following a traumatic event.
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Quote: "Every loud noise makes me jump, and I can't stop seeing what happened in my mind."
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Impairments and challenges: Avoidance of social situations and intrusive thoughts, leading to emotional numbness and difficulty functioning at work.
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Quote: "I can't go to the store without feeling anxious, like I'm always looking over my shoulder."
Chief complaint: Recurring flashbacks, nightmares, and hypervigilance following a traumatic event.
Quote: "Every loud noise makes me jump, and I can't stop seeing what happened in my mind."
Impairments and challenges: Avoidance of social situations and intrusive thoughts, leading to emotional numbness and difficulty functioning at work.
Quote: "I can't go to the store without feeling anxious, like I'm always looking over my shoulder."
Symptom 1: Flashbacks and nightmares
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Onset: Shortly after the traumatic event.
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Frequency: Several times a week.
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Ascendance: No improvements reported.
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Intensity: Moderate to severe.
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Duration: Ongoing for several months.
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Quote: "I wake up in a panic every night, feeling like I'm still there."
Onset: Shortly after the traumatic event.
Frequency: Several times a week.
Ascendance: No improvements reported.
Intensity: Moderate to severe.
Duration: Ongoing for several months.
Quote: "I wake up in a panic every night, feeling like I'm still there."
Symptom 2: Hypervigilance and exaggerated startle response
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Onset: Immediately after the trauma.
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Frequency: Daily.
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Ascendance: Worsens in stressful situations.
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Intensity: Severe.
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Duration: Several months.
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Quote: "I can't relax; I'm always on edge."
Onset: Immediately after the trauma.
Frequency: Daily.
Ascendance: Worsens in stressful situations.
Intensity: Severe.
Duration: Several months.
Quote: "I can't relax; I'm always on edge."
OBJECTIVE
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Assessment tools: Clinical interview and PTSD Checklist.
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Results: Symptoms align with a PTSD diagnosis, including avoidance behaviors, intrusive memories, and hyperarousal.
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Status: Ongoing.
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Risk assessment: No immediate self-harm risk identified.
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Approach: Trauma-focused CBT.
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Interventions: Normalized trauma reactions; taught grounding techniques and mindfulness; introduced exposure therapy to process traumatic memories.
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Rationale: Help the client process traumatic memories and reduce symptoms through structured interventions.
Assessment tools: Clinical interview and PTSD Checklist.
Results: Symptoms align with a PTSD diagnosis, including avoidance behaviors, intrusive memories, and hyperarousal.
Status: Ongoing.
Risk assessment: No immediate self-harm risk identified.
Approach: Trauma-focused CBT.
Interventions: Normalized trauma reactions; taught grounding techniques and mindfulness; introduced exposure therapy to process traumatic memories.
Rationale: Help the client process traumatic memories and reduce symptoms through structured interventions.
ASSESSMENT
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Response to treatment: Engaged in therapy but emotionally overwhelmed during trauma-focused work.
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Example: Difficulty tolerating prolonged exposure to trauma memories.
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Quote: "I feel like I'm reliving it when I talk about it."
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Challenges: Emotional overwhelm and avoidance of difficult topics.
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Therapist observations: The client needs more time to build trust in processing trauma. Consider pacing the work more slowly.
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Therapeutic alliance: Good rapport, but emotional dysregulation when confronting trauma-related topics.
Response to treatment: Engaged in therapy but emotionally overwhelmed during trauma-focused work.
Example: Difficulty tolerating prolonged exposure to trauma memories.
Quote: "I feel like I'm reliving it when I talk about it."
Challenges: Emotional overwhelm and avoidance of difficult topics.
Therapist observations: The client needs more time to build trust in processing trauma. Consider pacing the work more slowly.
Therapeutic alliance: Good rapport, but emotional dysregulation when confronting trauma-related topics.
PLAN
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Homework: Practice grounding exercises daily and continue trauma processing in small increments.
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Next session: Begin gradual exposure to trauma memories with additional emotional regulation strategies.
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Continued treatment: Weekly therapy with trauma work and relaxation techniques.
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Coordination of care: Consider a psychiatric evaluation for medication support if symptoms remain severe.
Homework: Practice grounding exercises daily and continue trauma processing in small increments.
Next session: Begin gradual exposure to trauma memories with additional emotional regulation strategies.
Continued treatment: Weekly therapy with trauma work and relaxation techniques.
Coordination of care: Consider a psychiatric evaluation for medication support if symptoms remain severe.
3. Social Anxiety Disorder
SUBJECTIVE
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Chief complaint: Intense fear of social situations, particularly public speaking and meeting new people.
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Quote: "I feel like everyone is judging me when I walk into a room."
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Impairments and challenges: Avoids social events and experiences significant distress when public interaction is required.
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Quote: "I have to turn down invitations because I can't handle the thought of talking to strangers."
Chief complaint: Intense fear of social situations, particularly public speaking and meeting new people.
Quote: "I feel like everyone is judging me when I walk into a room."
Impairments and challenges: Avoids social events and experiences significant distress when public interaction is required.
Quote: "I have to turn down invitations because I can't handle the thought of talking to strangers."
Symptom 1: Fear of negative evaluation
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Onset: Gradual, with increased severity during adolescence.
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Frequency: Most social interactions.
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Ascendance: Worsened with age and career pressures.
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Intensity: Severe.
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Duration: Several years per client report.
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Quote: "I get so nervous before speaking, I freeze up and can't say anything."
Onset: Gradual, with increased severity during adolescence.
Frequency: Most social interactions.
Ascendance: Worsened with age and career pressures.
Intensity: Severe.
Duration: Several years per client report.
Quote: "I get so nervous before speaking, I freeze up and can't say anything."
Symptom 2: Avoidance
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Onset: Gradual.
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Frequency: Frequent.
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Ascendance: More prominent recently due to work demands.
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Intensity: Severe.
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Duration: Ongoing.
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Quote: "I always find an excuse not to go to meetings."
Onset: Gradual.
Frequency: Frequent.
Ascendance: More prominent recently due to work demands.
Intensity: Severe.
Duration: Ongoing.
Quote: "I always find an excuse not to go to meetings."
OBJECTIVE
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Assessment tool: Social Anxiety Inventory (SAI).
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Results: Elevated score indicating high social anxiety.
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Status: Ongoing.
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Risk assessment: No immediate risks.
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Approach: CBT and exposure therapy.
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Interventions: Encouraged gradual exposure to feared social situations; worked on cognitive restructuring of negative beliefs about social interactions; implemented relaxation and breathing exercises.
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Rationale: Reduce avoidance and challenge distorted beliefs about social evaluation.
Assessment tool: Social Anxiety Inventory (SAI).
Results: Elevated score indicating high social anxiety.
Status: Ongoing.
Risk assessment: No immediate risks.
Approach: CBT and exposure therapy.
Interventions: Encouraged gradual exposure to feared social situations; worked on cognitive restructuring of negative beliefs about social interactions; implemented relaxation and breathing exercises.
Rationale: Reduce avoidance and challenge distorted beliefs about social evaluation.
ASSESSMENT
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Response to treatment: Engaging well in CBT, but progress is slow due to avoidance.
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Example: Attended a small work meeting but felt anxious the entire time.
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Quote: "It wasn't as bad as I thought, but I still felt really anxious."
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Challenges: High avoidance and negative self-talk.
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Therapist observations: Progressing with exposure, but fear of judgment remains a strong barrier.
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Therapeutic alliance: Motivated, but experiences significant anxiety during exposure exercises.
Response to treatment: Engaging well in CBT, but progress is slow due to avoidance.
Example: Attended a small work meeting but felt anxious the entire time.
Quote: "It wasn't as bad as I thought, but I still felt really anxious."
Challenges: High avoidance and negative self-talk.
Therapist observations: Progressing with exposure, but fear of judgment remains a strong barrier.
Therapeutic alliance: Motivated, but experiences significant anxiety during exposure exercises.
PLAN
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Homework: Daily exposures, starting with low-stakes interactions.
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Next session: Increase exposure tasks and review progress in challenging negative social beliefs.
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Continued treatment: Weekly sessions focused on increasing exposure and cognitive restructuring.
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Coordination of care: None at this time.
Homework: Daily exposures, starting with low-stakes interactions.
Next session: Increase exposure tasks and review progress in challenging negative social beliefs.
Continued treatment: Weekly sessions focused on increasing exposure and cognitive restructuring.
Coordination of care: None at this time.
4. Obsessive-Compulsive Disorder (OCD)
SUBJECTIVE
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Chief complaint: Intrusive thoughts and repetitive behaviors aimed at reducing anxiety, such as hand-washing and checking locks.
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Quote: "I can't stop checking the door, even though I know it's locked."
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Impairments and challenges: Significant distress from obsessions and compulsions, time-consuming rituals, and reduced ability to focus at work and in daily life.
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Quote: "It takes me hours to leave the house because I keep checking everything."
Chief complaint: Intrusive thoughts and repetitive behaviors aimed at reducing anxiety, such as hand-washing and checking locks.
Quote: "I can't stop checking the door, even though I know it's locked."
Impairments and challenges: Significant distress from obsessions and compulsions, time-consuming rituals, and reduced ability to focus at work and in daily life.
Quote: "It takes me hours to leave the house because I keep checking everything."
Symptom 1: Intrusive thoughts
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Description: Recurrent, intrusive thoughts about harm or danger.
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Onset: Early adulthood, worsening over time.
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Frequency: Several times a day.
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Ascendance: Increases with stress.
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Intensity: Severe.
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Duration: Ongoing for several years.
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Quote: "I can't stop thinking that something bad will happen if I don't check."
Description: Recurrent, intrusive thoughts about harm or danger.
Onset: Early adulthood, worsening over time.
Frequency: Several times a day.
Ascendance: Increases with stress.
Intensity: Severe.
Duration: Ongoing for several years.
Quote: "I can't stop thinking that something bad will happen if I don't check."
Symptom 2: Compulsive behaviors
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Description: Excessive hand-washing and checking locks.
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Onset: Gradual, worsening over the years.
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Frequency: Several times a day.
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Ascendance: Rituals have become more ingrained.
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Intensity: Moderate to severe.
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Duration: Ongoing.
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Quote: "I wash my hands until they're raw, but it never feels clean enough."
Description: Excessive hand-washing and checking locks.
Onset: Gradual, worsening over the years.
Frequency: Several times a day.
Ascendance: Rituals have become more ingrained.
Intensity: Moderate to severe.
Duration: Ongoing.
Quote: "I wash my hands until they're raw, but it never feels clean enough."
OBJECTIVE
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Assessment tool: Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
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Results: Elevated score indicating moderate to severe OCD symptoms.
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Status: Ongoing.
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Risk assessment: Skin damage from excessive hand-washing.
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Approach: Exposure and Response Prevention (ERP) and CBT.
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Interventions: Educated on the nature of OCD and exposure therapy; started ERP exercises to reduce checking and washing; encouraged journaling to track intrusive thoughts and compulsions.
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Rationale: Gradually reduce compulsive behavior and challenge the belief that rituals prevent harm.
Assessment tool: Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Results: Elevated score indicating moderate to severe OCD symptoms.
Status: Ongoing.
Risk assessment: Skin damage from excessive hand-washing.
Approach: Exposure and Response Prevention (ERP) and CBT.
Interventions: Educated on the nature of OCD and exposure therapy; started ERP exercises to reduce checking and washing; encouraged journaling to track intrusive thoughts and compulsions.
Rationale: Gradually reduce compulsive behavior and challenge the belief that rituals prevent harm.
ASSESSMENT
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Response to treatment: Initially resistant, but began engaging in ERP after a few sessions.
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Example: Reported reduced time spent checking locks, though ritualistic behavior remains significant.
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Quote: "I'm starting to believe the door is locked without checking, but it's still hard."
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Challenges: High distress during exposure tasks; compulsions are deeply ingrained.
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Therapist observations: Slow progress. Pace exposure tasks slowly to manage anxiety.
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Therapeutic alliance: Motivated, but faces intense discomfort during therapy.
Response to treatment: Initially resistant, but began engaging in ERP after a few sessions.
Example: Reported reduced time spent checking locks, though ritualistic behavior remains significant.
Quote: "I'm starting to believe the door is locked without checking, but it's still hard."
Challenges: High distress during exposure tasks; compulsions are deeply ingrained.
Therapist observations: Slow progress. Pace exposure tasks slowly to manage anxiety.
Therapeutic alliance: Motivated, but faces intense discomfort during therapy.
PLAN
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Homework: Continue ERP exercises, reduce checking time, and practice thought-stopping techniques.
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Next session: Increase ERP difficulty and review progress on intrusive thoughts.
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Continued treatment: Weekly therapy with gradual increases in exposure.
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Coordination of care: None currently required.
Homework: Continue ERP exercises, reduce checking time, and practice thought-stopping techniques.
Next session: Increase ERP difficulty and review progress on intrusive thoughts.
Continued treatment: Weekly therapy with gradual increases in exposure.
Coordination of care: None currently required.
5. Bipolar Disorder, Manic Episode
SUBJECTIVE
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Chief complaint: Feeling "on top of the world," unable to sleep, and very energetic with racing thoughts.
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Quote: "I feel unstoppable. I've got all these amazing ideas, and I can't stop talking!"
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Impairments and challenges: Difficulty maintaining relationships and work performance due to impulsive behavior, irritability, and excessive energy.
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Quote: "I spent all my money on things I don't need, and now I feel awful."
Chief complaint: Feeling "on top of the world," unable to sleep, and very energetic with racing thoughts.
Quote: "I feel unstoppable. I've got all these amazing ideas, and I can't stop talking!"
Impairments and challenges: Difficulty maintaining relationships and work performance due to impulsive behavior, irritability, and excessive energy.
Quote: "I spent all my money on things I don't need, and now I feel awful."
Symptom 1: Elevated mood, excessive energy, and impulsivity
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Onset: After a period of high stress.
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Frequency: Daily, with fluctuations.
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Ascendance: Worsened over the past week.
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Intensity: Severe.
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Duration: One week.
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Quote: "I'm running on no sleep and feel more alive than ever."
Onset: After a period of high stress.
Frequency: Daily, with fluctuations.
Ascendance: Worsened over the past week.
Intensity: Severe.
Duration: One week.
Quote: "I'm running on no sleep and feel more alive than ever."
Symptom 2: Racing thoughts and pressured speech
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Onset: Gradual, with rapid escalation.
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Frequency: Daily, throughout the day.
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Ascendance: Intensified recently.
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Intensity: Severe.
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Duration: Several days.
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Quote: "I've got so many ideas, I can't keep up with my own brain!"
Onset: Gradual, with rapid escalation.
Frequency: Daily, throughout the day.
Ascendance: Intensified recently.
Intensity: Severe.
Duration: Several days.
Quote: "I've got so many ideas, I can't keep up with my own brain!"
OBJECTIVE
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Assessment tools: Clinical interview and Mood Disorder Questionnaire (MDQ).
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Results: Elevated score indicating a manic episode consistent with Bipolar Disorder.
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Status: Acute.
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Risk assessment: Risk of financial or social consequences due to impulsivity; potential self-harm from lack of sleep.
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Approach: CBT focused on stabilization and mood regulation.
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Interventions: Psychoeducation about bipolar disorder and recognizing early signs of mood swings; sleep hygiene practices; mindfulness techniques for racing thoughts.
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Rationale: Reduce impulsive behavior and regulate mood through structured interventions.
Assessment tools: Clinical interview and Mood Disorder Questionnaire (MDQ).
Results: Elevated score indicating a manic episode consistent with Bipolar Disorder.
Status: Acute.
Risk assessment: Risk of financial or social consequences due to impulsivity; potential self-harm from lack of sleep.
Approach: CBT focused on stabilization and mood regulation.
Interventions: Psychoeducation about bipolar disorder and recognizing early signs of mood swings; sleep hygiene practices; mindfulness techniques for racing thoughts.
Rationale: Reduce impulsive behavior and regulate mood through structured interventions.
ASSESSMENT
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Response to treatment: Partially responsive, though energy levels remain high.
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Example: High energy in session, but able to focus on mindfulness techniques for brief periods.
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Quote: "It's hard to slow down, but I'm trying."
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Challenges: High impulsivity and difficulty following through on recommendations.
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Therapist observations: Manic symptoms require monitoring, and energy levels need careful management.
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Therapeutic alliance: Motivated, but struggles with the pacing of treatment.
Response to treatment: Partially responsive, though energy levels remain high.
Example: High energy in session, but able to focus on mindfulness techniques for brief periods.
Quote: "It's hard to slow down, but I'm trying."
Challenges: High impulsivity and difficulty following through on recommendations.
Therapist observations: Manic symptoms require monitoring, and energy levels need careful management.
Therapeutic alliance: Motivated, but struggles with the pacing of treatment.
PLAN
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Homework: Practice grounding techniques and monitor sleep hygiene.
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Next session: Focus on managing mood swings and preventing further impulsive behavior.
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Continued treatment: Weekly therapy, possibly with a medication management consultation.
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Coordination of care: Consider a referral for psychiatric evaluation for medication support.
Homework: Practice grounding techniques and monitor sleep hygiene.
Next session: Focus on managing mood swings and preventing further impulsive behavior.
Continued treatment: Weekly therapy, possibly with a medication management consultation.
Coordination of care: Consider a referral for psychiatric evaluation for medication support.
SOAP Note Examples by Specialty
The four-part structure stays the same across professions, but each specialty emphasizes different details.
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Psychiatry: Mental status, mood, and behavior. Subjective entries recount mood, thought patterns, or anxieties. Objective entries cover mental state exams and psychometric tools. Plans address medication management, therapy recommendations, and follow-up timelines.
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Pediatrics: Growth, development, and prevention. Subjective input comes from parents or guardians, and Objective data includes milestones, growth charts, and exam results. Plans emphasize immunizations, anticipatory guidance, and age-appropriate follow-ups.
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Obstetrics: Maternal and fetal health. Objective data may include blood pressure, weight gain, ultrasound results, and fetal heart tones. Assessments address gestational progress and risks such as preeclampsia.
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Therapy and counseling: Emotional and behavioral progress. Objective entries note affect, engagement, and body language. Plans specify interventions, homework, and areas to revisit.
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Dermatology: Subjective entries cover itching, burning, or aesthetic concerns. Objective entries describe lesion appearance, distribution, or biopsy results. Example: "red, scaly patches on the forearms" leading to "atopic dermatitis," with topical corticosteroids, daily moisturizer, and a follow-up in a month.
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Speech therapy: Subjective entries cover articulation, fluency, or language concerns. Objective entries include standardized test scores and session observations, such as difficulty with /r/ and /s/ sounds and the prompts needed in about 80% of attempts. Plans include varied sound-focused activities, phonological awareness exercises, home practice materials, and a scheduled progress review.
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Nursing: Subjective entries log patient concerns and symptoms. Objective data tracks vital signs, wound status, and medication effects. Plans include interventions, patient education, and when to escalate care.
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Urology: Subjective entries cover discomfort, frequency, or hematuria. Objective entries include physical exams, urinalysis, and imaging. Plans cover medication, procedures, lifestyle changes, and follow-up tests.
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Occupational therapy: Subjective entries reflect challenges in daily living. Objective data comes from motor assessments and session observations, such as the number of exercises completed. Assessments compare current performance against initial goals.
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Massage therapy: Subjective entries record client-described tightness or stress. Objective entries note palpation results, such as trapezius tension. Plans outline techniques, session frequency, and posture exercises.
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Social work: Subjective entries use direct client quotes. Objective entries note demeanor and body language. Plans include role-playing exercises for communication, workshops, mediation referrals, and follow-ups.
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Schizophrenia: Include the client's own statements (such as hearing voices or feeling watched) and verbatim quotes. Objective notes cover appearance, disorganized speech, unusual movements, signs of responding to internal stimuli, and affect. Plans address medication management and adherence, reality-testing techniques, and case management for stable housing and community resources.
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Eating disorders: Subjective entries record restrictive eating patterns and fear of gaining weight. Objective entries note physical appearance, such as being significantly underweight, and behaviors such as defensiveness about weight. Assessments may identify characteristics of Anorexia Nervosa, restricting type. Plans may include coordination with a nutritionist or primary care physician, cognitive restructuring, regular weigh-ins, food journaling, and discussion of more intensive care if the condition worsens.
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CBT: Subjective entries include the client's self-rating (e.g., 7 out of 10) and the impact on daily life. Objective entries note fidgeting, eye contact, and fast-paced speech. Assessments identify cognitive distortions such as catastrophizing. Plans include cognitive restructuring, new techniques, and stress management education.
Psychiatry: Mental status, mood, and behavior. Subjective entries recount mood, thought patterns, or anxieties. Objective entries cover mental state exams and psychometric tools. Plans address medication management, therapy recommendations, and follow-up timelines.
Pediatrics: Growth, development, and prevention. Subjective input comes from parents or guardians, and Objective data includes milestones, growth charts, and exam results. Plans emphasize immunizations, anticipatory guidance, and age-appropriate follow-ups.
Obstetrics: Maternal and fetal health. Objective data may include blood pressure, weight gain, ultrasound results, and fetal heart tones. Assessments address gestational progress and risks such as preeclampsia.
Therapy and counseling: Emotional and behavioral progress. Objective entries note affect, engagement, and body language. Plans specify interventions, homework, and areas to revisit.
Dermatology: Subjective entries cover itching, burning, or aesthetic concerns. Objective entries describe lesion appearance, distribution, or biopsy results. Example: "red, scaly patches on the forearms" leading to "atopic dermatitis," with topical corticosteroids, daily moisturizer, and a follow-up in a month.
Speech therapy: Subjective entries cover articulation, fluency, or language concerns. Objective entries include standardized test scores and session observations, such as difficulty with /r/ and /s/ sounds and the prompts needed in about 80% of attempts. Plans include varied sound-focused activities, phonological awareness exercises, home practice materials, and a scheduled progress review.
Nursing: Subjective entries log patient concerns and symptoms. Objective data tracks vital signs, wound status, and medication effects. Plans include interventions, patient education, and when to escalate care.
Urology: Subjective entries cover discomfort, frequency, or hematuria. Objective entries include physical exams, urinalysis, and imaging. Plans cover medication, procedures, lifestyle changes, and follow-up tests.
Occupational therapy: Subjective entries reflect challenges in daily living. Objective data comes from motor assessments and session observations, such as the number of exercises completed. Assessments compare current performance against initial goals.
Massage therapy: Subjective entries record client-described tightness or stress. Objective entries note palpation results, such as trapezius tension. Plans outline techniques, session frequency, and posture exercises.
Social work: Subjective entries use direct client quotes. Objective entries note demeanor and body language. Plans include role-playing exercises for communication, workshops, mediation referrals, and follow-ups.
Schizophrenia: Include the client's own statements (such as hearing voices or feeling watched) and verbatim quotes. Objective notes cover appearance, disorganized speech, unusual movements, signs of responding to internal stimuli, and affect. Plans address medication management and adherence, reality-testing techniques, and case management for stable housing and community resources.
Eating disorders: Subjective entries record restrictive eating patterns and fear of gaining weight. Objective entries note physical appearance, such as being significantly underweight, and behaviors such as defensiveness about weight. Assessments may identify characteristics of Anorexia Nervosa, restricting type. Plans may include coordination with a nutritionist or primary care physician, cognitive restructuring, regular weigh-ins, food journaling, and discussion of more intensive care if the condition worsens.
CBT: Subjective entries include the client's self-rating (e.g., 7 out of 10) and the impact on daily life. Objective entries note fidgeting, eye contact, and fast-paced speech. Assessments identify cognitive distortions such as catastrophizing. Plans include cognitive restructuring, new techniques, and stress management education.
Group and Family Therapy Notes
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Group therapy: Capture recurring themes, group dynamics (leadership roles, members needing encouragement), individual contributions, and interactions. The Plan sets goals for upcoming sessions and techniques to balance participation.
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Family therapy: List who attended and their roles. Record family concerns, individual insights, body language, interaction dynamics, and emotional tone. The Plan outlines strategies such as a family systems approach, active listening exercises, and actionable goals.
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Child therapy: Gather input from the child and caregivers. The Plan should cover session frequency, techniques like play therapy, family sessions, school collaboration, and age-appropriate coping strategies.
Group therapy: Capture recurring themes, group dynamics (leadership roles, members needing encouragement), individual contributions, and interactions. The Plan sets goals for upcoming sessions and techniques to balance participation.
Family therapy: List who attended and their roles. Record family concerns, individual insights, body language, interaction dynamics, and emotional tone. The Plan outlines strategies such as a family systems approach, active listening exercises, and actionable goals.
Child therapy: Gather input from the child and caregivers. The Plan should cover session frequency, techniques like play therapy, family sessions, school collaboration, and age-appropriate coping strategies.
SOAP Notes vs. DAP Notes
SOAP separates subjective and objective information, which makes it a strong default when notes will be read by other providers, payers, or auditors. Some solo therapists prefer DAP, which merges both into a single Data section. Choose the format your practice, payer, and team require.
SOAP Note Best Practices
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Be precise and detailed. Document specifics about the client's condition and progress over time.
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Stay objective. Keep the Objective section to observable, measurable facts.
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Use lists. Bullets improve readability in the Objective and Plan sections.
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Edit before finalizing. Remove redundant information that clutters the note.
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Write soon after the session, while details are fresh.
Be precise and detailed. Document specifics about the client's condition and progress over time.
Stay objective. Keep the Objective section to observable, measurable facts.
Use lists. Bullets improve readability in the Objective and Plan sections.
Edit before finalizing. Remove redundant information that clutters the note.
Write soon after the session, while details are fresh.
Common Mistakes to Avoid
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Lack of specificity: Vague statements hinder treatment planning.
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Omitting critical details: Include mood, emotional responses, and interventions used.
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Neglecting direct client quotes: Quotes add context and reveal perspective.
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Skipping analysis: Go beyond description to evaluate progress and themes.
Lack of specificity: Vague statements hinder treatment planning.
Omitting critical details: Include mood, emotional responses, and interventions used.
Neglecting direct client quotes: Quotes add context and reveal perspective.
Skipping analysis: Go beyond description to evaluate progress and themes.
How Long Should a SOAP Note Be?
Aim for half a page to a full page, depending on session complexity. Prioritize details that contribute to patient care.
Sentences or Bullet Points?
Use full sentences when nuance matters or the case is complex. Use bullets for straightforward cases and quick scanning. Pick the format that suits your audience, stays consistent over time, and meets your documentation requirements.
Do You Need a Note if Nothing Significant Happened?
Yes. Document every session. Regular notes create a complete timeline, help you monitor long-term progress, meet professional standards, and provide legal protection. Briefly cover client feedback, observations, current status, and plans.
What If a Session Runs Long or Short?
Document what was actually discussed. Note any deviations from the planned agenda, reflect the real content honestly, and summarize the main outcomes.
Correcting Mistakes in SOAP Notes
For paper notes:
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Strike through the error with a single line so the original stays legible.
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Add your initials and the date.
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Write the correct information next to it.
Strike through the error with a single line so the original stays legible.
Add your initials and the date.
Write the correct information next to it.
Never use correction fluid or erase content.
Handling Sensitive Information
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Include only clinically pertinent details.
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Use neutral, objective language.
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Store highly sensitive elements securely, using encrypted digital storage or secure physical locations.
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Limit access to those directly involved in care.
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Run regular privacy audits for HIPAA compliance and similar regulations globally.
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Keep up with legal and ethical standards through regular training.
Include only clinically pertinent details.
Use neutral, objective language.
Store highly sensitive elements securely, using encrypted digital storage or secure physical locations.
Limit access to those directly involved in care.
Run regular privacy audits for HIPAA compliance and similar regulations globally.
Keep up with legal and ethical standards through regular training.
Medical Terminology in SOAP Notes
Standardized terminology keeps communication precise, especially on multidisciplinary teams. Explain complex terms or uncommon abbreviations where possible, keep language consistent, and tailor complexity to your audience.
When a Client Requests Access to Their Notes
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Review the notes for clarity, accuracy, and privacy compliance, including third-party information.
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Prepare to explain clinical terminology and highlight key observations and plans.
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Offer a discussion rather than only handing over the notes.
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Respect their rights. Clients have a right to access their records under laws such as HIPAA in the United States. Document the request and what was shared.
Review the notes for clarity, accuracy, and privacy compliance, including third-party information.
Prepare to explain clinical terminology and highlight key observations and plans.
Offer a discussion rather than only handing over the notes.
Respect their rights. Clients have a right to access their records under laws such as HIPAA in the United States. Document the request and what was shared.
Continuity Across Multiple Providers
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Adopt a uniform format.
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Use shared electronic health records (EHRs) with real-time access.
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Reference other providers' notes.
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Hold regular collaboration meetings.
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Provide training and clear documentation guidelines.
Adopt a uniform format.
Use shared electronic health records (EHRs) with real-time access.
Reference other providers' notes.
Hold regular collaboration meetings.
Provide training and clear documentation guidelines.
SOAP Notes for Telehealth
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Document the delivery mode (video, phone, or another platform).
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Note the patient's remote environment, including privacy and distractions.
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Record any technical issues that affected the session.
Document the delivery mode (video, phone, or another platform).
Note the patient's remote environment, including privacy and distractions.
Record any technical issues that affected the session.
Integrating Cultural Considerations
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Subjective: Note language preferences, use of interpreters, beliefs affecting health decisions, and the role of family and community.
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Objective: Interpret observations in light of cultural norms.
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Assessment: Consider how cultural factors influence the condition and treatment.
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Plan: Choose culturally appropriate interventions and resources, and schedule follow-ups around cultural or religious commitments.
Subjective: Note language preferences, use of interpreters, beliefs affecting health decisions, and the role of family and community.
Objective: Interpret observations in light of cultural norms.
Assessment: Consider how cultural factors influence the condition and treatment.
Plan: Choose culturally appropriate interventions and resources, and schedule follow-ups around cultural or religious commitments.
Documenting Multiple Issues
Lead with the most critical issue and describe it fully. Briefly list secondary concerns in order of importance. Use subheadings per issue, keep the SOAP structure under each, and highlight any connections between issues.
SOAP Notes for Nurses
Nurses use SOAP notes to document patient visits, track symptoms and progress, record treatments administered, and build and update care plans.
SOAP Notes in Dentistry
Dentists use SOAP notes to record the patient's description of the problem (e.g., "sharp pain when I eat something cold"), exam findings such as cavities or gum swelling, a diagnosis such as dental caries or periodontitis, and a plan such as a filling, an oral hygiene strategy, or follow-up visits. The notes also support communication with other professionals and patient education.
SOAP Notes in Pediatric Care
Pediatric notes capture parent or guardian reports, growth measurements and milestones, the clinician's diagnosis, and a plan that may include treatment, medications, vaccinations, and home-care guidance. They support consistency, communication, efficient monitoring, and legal and ethical documentation.
How to Write SOAP Notes Faster With an AI Scribe
Writing SOAP notes takes significant time and attention. Automation tools, including AI medical scribes, can listen to a session and turn the conversation into a structured note, with each SOAP section populated for you. This lets you focus on the client instead of typing.Many of these platforms are designed to support HIPAA compliance, which helps protect patient confidentiality. Try S10.AI's AI Medical Scribe:
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HIPAA and insurance hassle-free
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Supports all note formats (SOAP, DAP, EMDR, and more)
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Seamless documentation for every therapy setting
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Record, dictate, type, or upload
HIPAA and insurance hassle-free
Supports all note formats (SOAP, DAP, EMDR, and more)
Seamless documentation for every therapy setting
Record, dictate, type, or upload
SOAP Note FAQsHow do SOAP notes differ across specialties?
The Subjective–Objective–Assessment–Plan structure is constant, but each specialty tailors it. Psychiatry focuses on mental status and medication. Pediatrics focuses on growth and development. Obstetrics focuses on maternal and fetal health. Therapy focuses on emotional progress. Dermatology focuses on lesion description. Speech therapy focuses on communication goals. Nursing tracks care delivery. Urology focuses on genitourinary findings. Occupational therapy focuses on function and independence.
What key details should a SOAP note include?
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Session details: client's full name, date of birth, date of service, start and end times, location, and diagnosis or diagnostic codes.
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Subjective: the client's statements, self-reported progress or challenges, and support systems or recent events.
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Objective: appearance, behavior, affect, body language, engagement, and coping strategy use.
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Assessment: clinical interpretation, effectiveness of interventions, and emerging concerns.
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Plan: interventions, homework, referrals, and follow-up plans, adjusted to the client's needs.
Session details: client's full name, date of birth, date of service, start and end times, location, and diagnosis or diagnostic codes.
Subjective: the client's statements, self-reported progress or challenges, and support systems or recent events.
Objective: appearance, behavior, affect, body language, engagement, and coping strategy use.
Assessment: clinical interpretation, effectiveness of interventions, and emerging concerns.
Plan: interventions, homework, referrals, and follow-up plans, adjusted to the client's needs.
What are progress notes, and how do they differ from general session records?
Progress notes are structured clinical summaries of key observations, interventions, and the client's response. They track progress toward therapeutic goals and inform future care. General session records may simply outline what took place. Progress notes typically follow a formal format such as SOAP.
What should a discharge summary include?
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A concise summary of treatment progress: goals addressed, interventions used, and outcomes.
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The client's current mental and emotional status at discharge, including remaining symptoms and level of functioning.
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The specific reason for discharge, such as goals achieved, client preference, referral, or nonattendance.
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Recommendations and next steps, including referrals and community resources such as the National Alliance on Mental Illness (NAMI).
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Documentation of communication with care team members, physicians, or family, with consent.
A concise summary of treatment progress: goals addressed, interventions used, and outcomes.
The client's current mental and emotional status at discharge, including remaining symptoms and level of functioning.
The specific reason for discharge, such as goals achieved, client preference, referral, or nonattendance.
Recommendations and next steps, including referrals and community resources such as the National Alliance on Mental Illness (NAMI).
Documentation of communication with care team members, physicians, or family, with consent.
Avoid vague statements like "client is fine," and confirm every section is complete before finalizing.
How do I write a SOAP note with limited objective information?
Record any observed cues, even minor or unchanged ones. State explicitly when the condition is stable, use precise language such as "Patient's condition remains unchanged," and use diagnostic tools or colleague input where available.
How should I structure the Plan for complex cases?
Include immediate and long-term goals, the next session date, and tasks to complete between appointments. Add referrals, patient education provided, and any new or adjusted medications.
What are examples of effective Subjective statements?
Direct quotes work best, such as "I've been feeling really anxious about work and haven't slept well in days" or "I'm feeling angry and frustrated. I can't relax in my own home."
How do I document progress, or lack of it, in the Assessment?
Compare current symptoms with previous presentations, noting changes in mood, functioning, or scores such as the PHQ-9. For lack of progress, note persistent symptoms and contributing factors. For example: "Symptoms appear consistent with major depressive disorder, recurrent episodes. Stress at work and relationship difficulties are likely contributing factors."
What Objective data belongs in a mental health SOAP note?
Include observable and measurable data such as appearance, affect, and body language. Examples: "Client was tearful and avoided eye contact throughout the session" or "Client appeared agitated, speaking rapidly and gesticulating frequently."
How can I make SOAP notes more concise without losing clinical detail?
Use clear, succinct language, stick to observable facts in the Objective section, write notes soon after the session, and include only clinically significant details.
How do I document a condition with fluctuating symptoms, like bipolar disorder?
Be specific in both Subjective and Objective sections. Record self-reported energy, sleep, and risky behaviors, along with observed speech patterns, psychomotor activity, and mood presentation. For example: "Client exhibited pressured speech and psychomotor agitation." The Assessment should reflect the current episode (e.g., "Current presentation consistent with Bipolar I Disorder, current episode manic"), and the Plan should address immediate risks, such as an urgent referral for medication adjustment.
How can AI scribes improve SOAP note quality and efficiency?
AI scribes transcribe encounters and identify key clinical information automatically. This reduces administrative burden, keeps formatting consistent, and lets clinicians focus on the patient.
What is the best way to automate SOAP note documentation?
Adopt a digital solution that uses AI, such as an EHR or practice management system with customizable templates and AI-powered transcription that populates note sections from the conversation.
Do AI scribes replace human scribes?
They are meant to augment human scribes, not replace them. AI scribes offer speed, consistency, and data extraction. Human scribes bring nuanced understanding. A hybrid approach, in which an AI-generated draft is reviewed and edited by a human, can deliver both accuracy and efficiency.Ready to cut documentation time? Try S10.AI's AI medical scribe and SOAP note generator.