SOAP Template

SOAP Notes

Learning how to write a SOAP note is generally straight-forward because it always follows a specific and precise structure, however it does take some practice.

SOAP notes include four headings that correspond with each letter of the acronym:

Subjective

Objective

Assessment

Plan

The notes and records you enter under each heading will depend on your clinical speciality, who your client is, and what you’re working on during your sessions together.

We’ve broken down the order of how to write a SOAP note, and suggestions for what should be included in each section as recommended by a review of peer-reviewed articles in StatPearls.

Subjective

This section is for subjective reporting of how your client says they are feeling during the session and what they report about their current symptoms. It can also contain information gathered from family members and reviews of past medical records.

Many mental health practitioners focus on what’s known as a “Chief Complaint”(CC) or the presenting problem in this section.

Even if the client reports multiple CC’s, it’s important to try to identify the most compelling problem so that you can ultimately provide an effective diagnosis.

Some general areas of inquiry as you try to identify the primary CC may include: history of present illness, medical history, review of systems, and current medications.

Here are some questions to ask to help uncover your client’s Chief Complaint:

  1. Describe your symptoms in detail. When did they start and how long have they been going on?
  2. What is the severity of your symptoms and what makes them better or worse?
  3. What is your medical and mental health history?
  4. What other health-related issues are you experiencing?
  5. What medications are you taking?

Make sure any opinions or observations you include in the section are attributed to who said them — whether it’s yourself or your client. Because this is a subjective section, you don’t want to pass off any of this information as fact.

Objective

This part of your SOAP note should be made up of physical findings gathered from the session with your client.

Some examples include:

  • Vital signs
  • Relevant medical records or information from from other specialists
  • The client’s appearance, behavior, and mood in session

Note: This section should consist of factual information that you observe and not include anything the patient has told you.

Assessment

This section combines all the information gathered from the subjective and objective sections. It’s where you describe what you think is going on with the patient.

You can include your impressions and your interpretation of all of the above information, and also draw from any clinical professional knowledge or DSM criteria/therapeutic models to arrive at a diagnosis (or list of possible diagnoses).

Plan

The last section of your SOAP note should outline your plan for next steps to treat the patient.

It can include short and long term goals for your patient and be as specific as what you plan to work on in the next session or as general as your expectations for the duration of treatment.

Therapy SOAP note examples

If you’re looking for SOAP note examples for social workers, here are some sample client notes that may help behavioral health practitioners better understand how to write a SOAP note.

Subjective

Client reports feeling more anxious this week. She said she felt more jittery and on-edge, and reports having more anxious thoughts that were harder to control.

Objective

During the session the client was fidgety, wringing her hands and speaking quickly. She appeared to have difficulty concentrating and asked me to repeat questions multiple times before responding. Client described a fear of losing her job and her housing, though admitted she didn’t have any evidence those events were imminent.

Assessment

Based on the client’s reports and in-session observations, the client’s anxiety has increased but continues to meet criteria for generalized anxiety disorder (GAD).

Plan

Recommended that client see a primary care physician to rule out any thyroid or other medical condition. Client will continue coming to therapy once a week for the foreseeable future to treat anxiety through cognitive behavior therapy (CBT). Also recommended client try some meditation and other mindfulness techniques at home in between sessions.