SOAP notes are one of the most widely used documentation formats in healthcare — and increasingly in mental health practice. The structure is simple: four sections that capture the essential elements of a clinical encounter in a consistent, scannable way.

This guide covers what each section means in a therapy context, how to write each one well, and when SOAP notes are — and aren’t — the right choice.

What SOAP stands for

S — Subjective
What the client reports: their words, their experience, how they describe what’s happening for them.

O — Objective
What you observe: clinical observations that don’t depend on the client’s self-report — behavior, affect, appearance, functioning.

A — Assessment
Your clinical interpretation: what the information means, how the client is progressing, any changes to your formulation.

P — Plan
What happens next: interventions used this session, homework assigned, next session focus, any referrals or changes to the treatment plan.

The logic is that each section represents a different type of information — and keeping them separate makes the note clearer and easier to use.

The Subjective section

This is the client’s perspective. What did they bring to the session? How do they describe their experience?

What to include:

  • The client’s presenting concern for this session
  • Their self-reported mood, symptoms, or functioning since the last session
  • Direct quotes where the client’s own words are particularly significant
  • Any significant life events they reported

What to avoid:

  • Your interpretations — those belong in Assessment
  • Clinical observations — those belong in Objective
  • Vague summaries that could apply to anyone

Example:

Client reports feeling “less anxious than last week” after practicing the breathing exercise daily. States she had one panic episode on Wednesday before a work presentation but was able to use the technique. Reports sleep has improved to approximately 7 hours per night.

A note on direct quotes: Use them when the client’s exact phrasing is clinically significant — when it reveals something about how they conceptualize their experience that paraphrase would flatten. Don’t fill the section with quotes just to seem thorough.

The Objective section

This is what you observed — not what the client told you, but what you could have documented regardless of what they said.

What to include:

  • Appearance (appropriate dress, hygiene if relevant)
  • Behavior during the session (cooperative, guarded, tearful, agitated)
  • Affect — the observable expression of emotion (flat, constricted, labile, appropriate to content)
  • Mood — the client’s subjective emotional state as reported (distinct from affect)
  • Speech (rate, volume, coherence)
  • Cognitive functioning (orientation, concentration, memory, as appropriate)
  • Any risk-related observations

What to avoid:

  • Interpreting what the observations mean — that’s Assessment
  • Reporting what the client said about how they feel — that’s Subjective

Example:

Client presented on time, appropriately dressed. Appeared relaxed compared to previous sessions. Affect bright, congruent with reported mood. Speech normal rate and volume. No signs of distress observed. Maintained good eye contact throughout.

In telehealth sessions: Note the modality (video call) and any relevant observations about the client’s physical environment or technology issues. You’ll be limited in some observations (full body language, for instance) — that’s fine to acknowledge.

The Assessment section

This is where you think clinically. What does everything in Subjective and Objective mean? How is the client progressing?

What to include:

  • Your clinical impression of the session
  • Progress toward treatment goals — are things improving, stable, or deteriorating?
  • Any changes to your diagnostic impression or formulation
  • Risk assessment if relevant
  • Response to interventions

What to avoid:

  • Simply restating the Subjective section
  • Being so vague that the note could apply to any client in any session

Example:

Client demonstrates consistent progress in anxiety management. Application of breathing technique during high-stress situation indicates skill generalization beyond the session. Sleep improvement consistent with reduced baseline anxiety. Current presentation consistent with anxiety disorder, mild severity. No safety concerns identified. Treatment goals remain appropriate.

The Assessment section is where your clinical judgment lives. A good assessment note makes it clear that you’re thinking — not just recording.

The Plan section

What comes next?

What to include:

  • Interventions used in this session
  • Homework or between-session tasks assigned
  • Focus for the next session
  • Any changes to frequency, modality, or treatment approach
  • Referrals made or pending
  • Next appointment date

What to avoid:

  • Generic plans that don’t reflect the specific client (“continue therapy”)
  • Homework assigned so vaguely the client couldn’t follow through

Example:

Continued work on cognitive restructuring for performance anxiety. Reviewed breathing technique — client demonstrated correct use. Assigned: practice 4-7-8 breathing for 5 minutes each morning and immediately before high-stakes situations this week; note triggers and response in provided log. Next session: review log, introduce progressive muscle relaxation. Next appointment: [date].

Putting it together: a complete SOAP note example

Date: [date] | Session: 6 | Duration: 50 minutes | Modality: In-person

S: Client reports mood has been “pretty good, maybe a 6 or 7 out of 10” for most of the week. Had a difficult conversation with her mother over the weekend that left her feeling criticized and “like nothing I do is ever enough.” Reports she did not complete the thought record homework, stating she “didn’t know what to write” when she felt upset. Sleep remains disrupted, averaging 5–6 hours.

O: Client presented on time. Appeared tired; dark circles under eyes noted. Affect initially flat, becoming more animated when discussing the conflict with her mother. Occasional tearfulness when describing the weekend conversation. Speech coherent, normal rate. No safety concerns identified.

A: Client’s core belief around inadequacy continues to be activated strongly in family-of-origin context. Incomplete homework may reflect avoidance pattern or insufficient psychoeducation on thought record use. Mood improvement noted from baseline but sleep disruption and family conflict represent ongoing stressors. Progress toward treatment goals moderate; some regression noted this week relative to previous session. No change to diagnosis or risk level.

P: Explored weekend conflict using thought record format in-session to address homework avoidance and model technique. Discussed core belief activation in family context. Assigned: complete one thought record before next session for any situation rated 5/10 or above on distress; client agreed and identified two likely situations. Sleep hygiene reviewed. Next session: review thought record, continue work on family-of-origin patterns. Next appointment: [date].

SOAP note example: depression session

Date: [date] | Session: 14 | Duration: 50 min | Modality: In-person

S: Client reports mood has been “a bit lower this week — maybe a 4 out of 10.” States he had two days where he didn’t leave the apartment and “didn’t see the point.” Completed one of three planned behavioral activation tasks (grocery shopping). Reports sleep approximately 10 hours but still waking feeling unrefreshed. Denies suicidal ideation.

O: Client presented 5 minutes late, appearing disheveled. Psychomotor slowing noted — longer latency before responding. Affect flat, with brief brightening when discussing the completed grocery task. Eye contact intermittent. Speech slower than previous sessions. No agitation or restlessness observed.

A: PHQ-9 this session: 17 (up from 13 at session 11). Current presentation consistent with moderate-severe depression episode with emerging behavioral withdrawal pattern. Reduced behavioral activation task completion and increased isolation are concerning early warning signs. The one completed task was noted as a genuine point of mastery — important to reinforce. No active safety concerns; passive ideation denied and consistent with previous sessions. Adjusting session focus to prioritize behavioral activation before cognitive work.

P: In-session: reviewed barriers to task completion; identified low energy and “it won’t matter” cognition as primary obstacles. Used motivational interviewing to strengthen commitment. Revised homework: one behavioral activation task per day, client’s choice, duration 10 minutes minimum (reduced from previous to increase likelihood of success). PHQ-9 to be readministered next session. If PHQ-9 ≥18 next session, discuss psychiatric consultation. Next appointment: [date].

SOAP note example: trauma (PTSD session)

Date: [date] | Session: 9 | Duration: 55 min | Modality: In-person

S: Client reports three nights of nightmares this week, all involving the accident scene. States she “almost called in sick to work on Thursday” due to hypervigilance on the commute. Reports using the grounding technique twice — both times it helped reduce distress. Rates current distress at 7/10. “I’m tired of being scared all the time.”

O: Client presented on time. Hypervigilance noted on entry — scanned the room before sitting. Affect anxious, somewhat constricted. Startled visibly when a door closed in the hallway. Speech normal rate and coherence. No dissociation observed during session. Remained present and engaged throughout.

A: PCL-5 this session: 44 (was 52 at intake). Meaningful symptom reduction in avoidance cluster; hyperarousal remains elevated. Grounding technique is being applied successfully outside sessions — positive indicator for skill generalization. Nightmare frequency has not reduced yet, consistent with expected trajectory at this phase of treatment. Safety: no SI. Firearm access: confirmed no access (discussed session 4, documented). Risk: low.

P: Continued Phase 2 stabilization (resource installation). Reviewed and strengthened grounding technique. Introduced sleep hygiene protocol specific to trauma-related sleep disruption. Assigned: grounding practice before bed nightly; sleep log (time in bed, estimated hours, nightmares yes/no). No trauma processing this session — client not yet fully resourced. Next session: assess readiness for Phase 3. Next appointment: [date].

When SOAP notes work well

SOAP notes are a good fit when:

  • You need a format that’s compatible with medical settings or multidisciplinary teams
  • Your practice requires standardized documentation for billing or insurance
  • You want a consistent structure that’s easy to complete and easy to scan
  • You’re in a clinical supervision context where case presentation benefits from a structured format

When another format might work better

SOAP notes aren’t the only option — and they’re not always the best one.

DAP notes (Data, Assessment, Plan) combine Subjective and Objective into a single Data section. This is simpler and works well for private practice where a strict S/O distinction isn’t required.

BIRP notes (Behavior, Intervention, Response, Plan) are common in behavioral health and community mental health settings. They emphasize the client’s response to interventions — useful in CBT-focused work.

Narrative or process notes are better suited to approaches like psychodynamic or gestalt work, where the relational and process dimensions are central and don’t fit neatly into structured sections.

Choose the format that matches your clinical approach and practice context. The best note format is one you’ll use consistently and that serves your clinical thinking — not one imposed by convention.

Common mistakes in SOAP notes

Assessment that just restates Subjective. “Client reports feeling anxious about work” in S, then “client is anxious about work” in A — this isn’t an assessment, it’s a repetition. The A section should show your clinical reasoning.

Plans that aren’t specific. “Practice coping skills” is not a plan. “Practice 4-7-8 breathing twice daily and before any situation anticipated to cause anxiety above 6/10” is a plan.

Objective observations mixed into Subjective. Your observation that the client appeared tearful is Objective; the client reporting that she cried is Subjective. Keeping these separate makes the note clearer.

Writing SOAP notes as if they’re legal documents. Notes should be professional and accurate — but they should also reflect your actual clinical thinking. Overly defensive or sanitized notes lose clinical value.

How long should a SOAP note be?

Long enough to capture what matters; short enough that you’ll actually write it consistently.

For a routine 50-minute session: S and O together typically run 3–5 sentences each. A is 3–4 sentences. P is 4–6 lines. Total: one page or less.

If your notes routinely run to three pages, something has gone wrong — either you’re over-documenting, or you’re processing in the note rather than in supervision.

Write the note immediately after the session. The S section especially fades fast — direct quotes and specific mood ratings are gone within the hour.

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