Writing Effective SOAP Notes in Therapy
SOAP notes are the backbone of clinical documentation across nearly all mental health professions. They provide a structured way to summarize sessions while maintaining clarity, professionalism, and compliance with industry standards.
This guide breaks down each component of SOAP notes and offers practical examples for therapists and students.
S — Subjective
The Subjective section captures what the client reports. This may include:
- Emotions
- Symptoms
- Stressors
- Updates since the last session
- Relevant life events
Example:
"Client reports increased anxiety when preparing for work, stating, 'I feel a knot in my chest every morning.'"
This section always uses the client's voice and perspective.
O — Objective
The Objective section includes what the therapist directly observes:
- Mood and affect
- Behavior
- Appearance
- Speech patterns
- Orientation and cognition
It may also include measurable data, such as scores on screening tools.
Example:
- Affect: constricted
- Mood: self-reported as "anxious but functional"
- Thought process: linear
A — Assessment
This is the clinical interpretation of the session. It connects the subjective + objective information and relates it to the client's goals or diagnosis.
Example:
"Client's symptoms remain consistent with generalized anxiety, though they demonstrate improved insight into triggers."
The assessment is where therapeutic reasoning happens.
P — Plan
The Plan section outlines the next steps:
- Homework assignments
- Skills to practice
- Interventions to continue
- Safety considerations
- Date of next session
Example:
- Continue CBT-focused restructuring
- Introduce grounding techniques
- Schedule follow-up for next Tuesday
Why SOAP Notes Matter
SOAP notes enhance continuity of care, improve treatment outcomes, protect therapists legally, and support ethical practice. A well-written SOAP note is not just documentation — it's a roadmap for clinical progress.
With the right structure, documentation becomes faster, clearer, and more effective.