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Behavioral Health Therapist
20-25 minutes

Subjective, Objective, Assessment, Plan (Training & Evaluation)

This SOAP (T&E) template is crafted for mental health professionals to efficiently document therapy sessions. It offers a structured approach to record subjective symptoms, objective observations, assessments, and treatment strategies. Perfect for monitoring client progress, therapeutic interventions, and planning subsequent sessions, this template ensures thorough documentation, essential for effective mental health care. Optimized for integration with s10.ai, an AI medical scribe, it streamlines the documentation process and improves the precision of clinical notes, encouraging clinicians to adopt this tool for enhanced practice efficiency.

3,059 uses
4.5/5.0
E
Ethan Caldwell
Template Structure

Organized sections for comprehensive clinical documentation

Symptom Description and Subjective Report:
The client acknowledged the following symptoms
[Include all symptoms discussed]
[Describe how often symptoms occur]
[Describe how long symptoms last when they occur]
[Describe severity of symptoms such as mild, moderate, and severe]
[Describe impact on the client's activities of daily living and daily functioning]
[Report on privacy for confidential conversation]
[Use "the client reported" when describing symptoms]
Objective Content:
[Describe at least 3 main themes the client spoke about during the session]
[Specific details the client shared, such as quotes from the client]
[Describe at least 3 therapeutic interventions used during the session and why the intervention was used]
[Explanation of client's response to interventions]
[Use "the client reported" and "the therapist used" when describing interventions used and themes discussed by the client]
Additional Notes / Assessment:
[Additional comments about client’s progress]
[Location where session occurred such as at home, in the car, at the office]
[Assessments given and their scores]
Plan:
[Ongoing plan for treatment and Homework given]
[Topic of discussion for next session and expectations for what will occur between sessions]
[Time and date of next session]
[Type of next session]
(Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)
Sample Clinical Note

Example of completed documentation using this template

Symptom Description and Subjective Report:  
The client reported experiencing symptoms such as anxiety, sleep disturbances, and irritability. These symptoms are noted to occur daily, lasting several hours each time. The severity is described as moderate, affecting the client's concentration at work and social interactions. The client confirmed that privacy was maintained for a confidential discussion.
Objective Content:  
The client expressed feeling overwhelmed by work duties, tension in personal relationships, and low self-esteem. The client stated, "I feel like I'm constantly on edge and can't relax." Cognitive-behavioral therapy was utilized to address negative thought patterns, mindfulness exercises were employed to alleviate anxiety, and role-playing was used to enhance communication skills. The client reported feeling more at ease after the mindfulness exercises and showed a willingness to continue practicing these techniques.
Additional Notes / Assessment:  
The client has made progress in identifying anxiety triggers and is more open to discussing personal issues. The session took place at the therapist's office. The Beck Anxiety Inventory was administered, revealing a score indicative of moderate anxiety.
Plan:  
The treatment plan includes continuing cognitive-behavioral therapy and practicing mindfulness exercises at home. The client was assigned homework to journal about daily stressors and practice deep breathing exercises. The next session will focus on coping strategies for work-related stress, with plans to explore new relaxation techniques between sessions. The next session is scheduled for November 15, 2023, and will be an individual therapy session.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive Symptom Description and Subjective Report template, designed to streamline the assessment and treatment planning process. This template allows healthcare professionals to meticulously document client-reported symptoms, including frequency, duration, and severity, while evaluating their impact on daily living activities. It ensures confidentiality in client conversations and provides a structured format for capturing objective content, such as key themes and therapeutic interventions discussed during sessions. Clinicians can easily track client progress, record session locations, and document assessment scores. The template also facilitates the creation of a detailed treatment plan, including ongoing strategies, homework assignments, and future session planning. By adopting this template, clinicians can enhance their practice efficiency, improve patient outcomes, and ensure comprehensive care documentation.
Frequently Asked Questions

Common questions about this template and its usage

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Subjective, Objective, Assessment, Plan (Training & Evaluation)