Writing SOAP Notes for Therapy Documentation Cheat Sheet

You’ve just finished an intense therapy session, your mind buzzing with insights and your client’s breakthroughs. But when it’s time to document, you’re stuck, unsure where to begin or how to structure your notes. If this sounds familiar, you’re not alone.

SOAP notes provide a structured way to track client progress, maintain records, and meet ethical and legal standards. Whether you’re an experienced therapist or just starting out, mastering SOAP notes will boost both the efficiency and effectiveness of your work. These notes are crucial for insurance reimbursements, employer requirements, and legal protections.

A study highlighted that poor documentation practices adversely affect patient management and continuity of care, resulting in medicolegal issues due to incomplete and inadequate records. Moreover, nursing documentation errors, such as incorrect patient information, account for up to 72% of all electronic health record-related risk issues.

With a standardized structure, SOAP notes help you create clear, objective, and actionable records of each session. This guide will teach you how to write effective SOAP notes, offer a SOAP note cheat sheet, and provide free templates to help streamline the process with modern coaching tools.

What Are SOAP Notes and Why Are They Essential?

SOAP, an acronym for Subjective, Objective, Assessment, and Plan, was coined by Dr. Lawrence Weed in the 1960s as a standardized method for documenting patient encounters. Initially designed for medical use, the SOAP format and SOAP note cheat sheet are now widely adopted across mental health, occupational therapy, physical therapy, other healthcare professions and in the broad spectrum of therapy.

Why are SOAP notes important in therapy?

Insurance reimbursement: If a client’s treatment is covered by insurance, a SOAP note or a SOAP note cheat sheet serves as essential documentation to justify claims and secure reimbursement.
Professional and legal security: Proper documentation protects you from liability issues, ensuring that all your sessions are accurately recorded in case of audits or legal disputes.
Employer and organizational compliance: Many employers and institutions require you to maintain structured records for internal audits and quality assurance.
Continuity of care: A well-written SOAP note ensures consistency in therapy, making it easier for you to track progress over multiple sessions.
Ethical and professional standards: SOAP notes help you maintain accuracy and integrity in documentation. Fabricating or altering details is unethical and can compromise both your practice and your client’s well-being.

By following the SOAP format, you maintain clear, structured, and objective documentation, enhancing both client care and professional accountability.

Breaking Down the SOAP Format

Each SOAP note and a SOAP note cheat sheet follows a structured format designed to ensure comprehensive, concise, and actionable documentation.

Remember:

“If it’s not documented, it didn’t happen!”

Here’s a breakdown of each section, along with important details you should include to improve the accuracy and effectiveness of your notes:

1. Subjective (S)

The Subjective section captures your client’s personal experience, thoughts, and reported concerns. It is essential to collect relevant information that defines the problem and provides context for your therapy sessions. This information can come from two key areas: past medical history and the occupational profile of the client.

In this section, it’s important to document direct quotes or paraphrases from your client, which can reflect their current state, concerns, or goals. For example:

Past experiences: “I lived by myself and was completely conflicted in being independent and alone” can help define the client’s baseline level of functioning.
Client’s complaints: “I can’t, I’m in too much pain!” offers a direct expression of the client’s experience that you will address in treatment.
Client’s goals: “I want to be more stress-free and decisive” allows you to tailor your therapeutic interventions to meet their personal objectives.
Client’s perspective on progress: For instance, “I think I have gone backward or have not aligned with my targets” helps in evaluating whether the client’s self-assessment aligns with your observations.

TIP:

Incorporate your client’s own words whenever possible – it strengthens the authenticity of your notes. Before starting, review the previous session’s notes to highlight any changes or new developments. For new clients, make sure to note the reason for their first visit to provide context.

Additionally, pain scores or any self-reported symptoms like anxiety or stress levels are documented here as they are subjective by nature. For example: “Pain rated 6/10.” While pain can be observed in the Objective section (e.g., self-bracing during crying), the Subjective section should reflect the client’s own expression of their condition.

Be mindful to avoid including results from standardized tests or screening assessments in this section; those belong in the Objective section. Instead, focus on what your client is reporting and their own perspective on their condition and progress. This ensures the Subjective nature of the information remains clear.

2. Objective (O)

The Objective section documents the observable, measurable facts that are directly related to your client’s condition. This section is based on your clinical observations or data obtained from assessments, evaluations, or screenings.

Examples of what to include in the Objective section:

Physical data: Range of Motion (ROM), strength, vital signs, skin conditions, wound status, or any other physical measurements.
Behavioral observations: The client’s facial expressions, speech patterns, or any notable changes in their body language.
Functional observations: Document how your client performs in activities or tasks, such as transferring, walking, or managing daily tasks such as communication, decision-making, relationship maintenance, and more, using standardized formats for more precise applications.

These observations should be factual and free from interpretation. For example, you may write: “Client was able to complete 5 sit-to-stand transfers with minimal assistance,” or “Client maintained good eye contact throughout the session, showing more confidence than last time.”

Avoid going into assessments or interpretations in this section. Save those for the Assessment section. For instance, if a client’s facial expression shows signs of anxiety, note it objectively as: “Client appeared anxious, fidgeted with hands,” but do not analyze or suggest causes for this behavior yet.

3. Assessment (A)

The Assessment section is where you provide your professional interpretation of the information collected in both the Subjective and Objective sections. This is your opportunity to analyze your client’s situation and assess their response to treatment.

Key points to include in the Assessment section:

Client’s progress: Reflect on how your client is progressing with their action plans & goals. For example: “Client shows improvement in pain tolerance and is able to engage in light activities without discomfort.”
Response to treatment: If the client’s progress is slower than expected, you might note: “Client appears to be less cooperative during exercises, possibly due to emotional distress.”
Changes in condition: Any improvements or setbacks should be documented. For example: “Client’s overall mobility has decreased due to increased pain during communicating childhood trauma.”
Client’s rehab potential: Based on the current progress, you may indicate their potential for healing. For instance: “Client is showing potential for improvement with continued treatment and increased motivation.”
Recommendations: You may include suggestions for additional resources or therapy interventions. For example: “Recommend referral to a psychologist or similar specialist for further evaluation.”

Be cautious of using terms like “plateau,” as it may suggest that the client has reached the end of their treatment potential, which might not always be the case. Instead, frame the progress as “slower than expected” to remain open to further improvements.

4. Plan (P)

The Plan section is a detailed outline of the next steps in treatment. It should connect directly to your analysis in the Assessment section, addressing how you will continue to work toward the client’s goals and overcome any barriers that have been identified.

Here’s what to include in the Plan section:

Short-term and long-term goals: Set and track the measurable goals for your client to work toward in the short and long term. Example: “Short-term goal: Increase leadership skills to improve confidence and work-life management. Long-term goal: Return to independent living without assistance.”
Treatment adjustments: If your client is not progressing as expected, modify your plan to reflect changes. For example: “Increase frequency of emotional therapy sessions to address control and anger concerns.”
Client education: If the client requires specific education (e.g., techniques for managing pain/emotions at home), it should be documented here. Example: “Client will be educated on safe techniques to prevent further triggers.”
Family/client involvement: If applicable, note any need for family or caregiver involvement. Example: “Client’s family will be educated on assisting with bonding to prevent loneliness.”
Discharge plans: If applicable, indicate plans for discharge or transition to other care providers. Example: “Client will transition to another specialist once the current part of the plan is attained.”
Referrals: If necessary, include any referrals to specialists or other professionals for further support. Example: “Refer to a nutritionist for dietary advice to assist with weight management.”

The Plan section outlines the specific steps you will take to ensure continued improvement and progress in the client’s therapy.

By following this framework, your SOAP notes and your SOAP note cheat sheet will be structured, effective, and comprehensive. The Subjective section captures the client’s personal experiences, the Objective section focuses on measurable observations, the Assessment section allows you to analyze progress, and the Plan section outlines the next steps to continue improving client outcomes.

Best Practices for Writing Effective SOAP Notes

While SOAP notes provide a structured approach, writing them effectively requires skill and attention to detail. Here are key best practices to improve clarity, consistency, and utility in your documentation:

Be concise but specific – Keep your notes brief while ensuring you capture all essential details. Avoid unnecessary filler words.
Use professional language – Maintain an objective and neutral tone. Avoid personal opinions and ensure all statements are fact-based and evidence-supported.
Document immediately after sessions – Writing notes while details are fresh ensures accuracy and completeness.
Avoid jargon or subjective phrases – Use clear, clinical language rather than ambiguous or emotionally charged terms.
Maintain confidentiality – Never include information that could breach privacy regulations, such as unnecessary personal details.

By following these best practices, your SOAP notes will be effective tools for tracking client progress and ensuring high-quality therapy sessions.

Common Mistakes to Avoid in SOAP Notes

Writing SOAP notes can be challenging, even for experienced therapists. Here are some common mistakes and tips on how to avoid them:

Overcoming writer’s block: When you’re staring at a blank page, start with the easiest section. If the Assessment is tricky, try beginning with the Objective observations. This helps you break the resistance and get your notes moving.
Staying objective: Keep your language professional and free from bias. Avoid phrases like “Client was difficult and uncooperative.” Instead, document the facts: “Client expressed reluctance to engage in suggested exercises.” Don’t be vague, and save the interpretation for the Assessment section.
Avoid overloading with details: Be concise and document only the relevant information that impacts treatment decisions. Too much information can clutter your notes and make them harder to use.
Skipping the assessment section: It’s easy to forget to analyze the subjective and objective data. However, the Assessment section is essential for keeping up with progress notes and guiding future treatment.
Failing to outline a clear plan: The Plan section should always include actionable steps. Without it, your SOAP note cheat sheet lacks direction and can leave gaps in future sessions.
HIPAA Compliance: Ensure your documentation adheres to HIPAA guidelines. It’s not just about what you write but also how you store and share it. Stay updated on best practices for secure note-taking and data management.
Writing after long delays: Waiting too long to document can lead to incomplete or inaccurate records. Always try to document immediately or shortly after the session to keep your notes accurate.
Time management: Make time for your notes. Set aside specific time slots after each session to document, treating it like an essential part of your practice. Consider using a therapy timer or a tool like Simply.Coach that offers SOAP notes to help manage both your sessions and your note-writing time efficiently.

By addressing these common challenges and avoiding these mistakes, you’ll enhance the quality and reliability of your therapy documentation, ensuring it’s clear, concise, and valuable for both you and your clients.

Downloadable Templates Examples by Simply.Coach

With Simply.Coach, you can access downloadable templates and customized examples designed to streamline your documentation process. These resources help you save time while ensuring that your SOAP note cheat sheet is accurate and consistent.

SOAP Note Cheat Sheet

SOAP Note Cheat Sheet

SOAP Note Cheat Sheet Anger Management Example

SOAP Note Cheat Sheet Anger Management Example

SOAP Note Cheat Sheet Panic Attacks Example

SOAP Note Cheat Sheet Panic Attacks Example

SOAP Note Cheat Sheet Example of Navigating Divorce

SOAP Note Cheat Sheet Example of Navigating Divorce

SOAP Note Cheat Sheet Procrastination Example

SOAP Note Cheat Sheet Procrastination Example

Simply.Coach offers a variety of downloadable templates and examples, making it easier for you to maintain structured, professional SOAP notes. Let’s look at it in more detail!

How Simply.Coach Streamlines SOAP Note Documentation

Writing SOAP notes manually can be time-consuming and tedious, especially with a growing client base. This is where Simply.Coach comes in as a game-changing solution for therapists and mental health professionals.

Automated session feedback – Save time with pre-built forms & templates and structured documentation workflows.
Customizable therapy frameworks – Adapt notes to fit your specific therapy approach and methodologies.
Client relationship management – Store all SOAP notes securely in a centralized, organized dashboard and in client workspaces.
Seamless integration – Sync with Google Calendar, Zoom, email and other major payment platforms to keep your workflow efficient. Also, schedule your sessions and receive payments on time at your and your client’s convenience and flexibility. Further, take automated session notes and SOAP notes as you please for future reference.
HIPAA, GDPR & SOC2 Compliance – Ensure secure, private, and legally compliant documentation.

By using Simply.Coach, therapists can reduce administrative burdens, improve documentation accuracy, and focus more on client care.

Conclusion

Mastering SOAP note documentation streamlines your therapy practice, ensuring thorough tracking of client progress and legal compliance. With the right tools, you can automate workflows, use pre-built templates, and maintain HIPAA-compliant records, saving time and enhancing client care.

By using a SOAP note cheat sheet and a structured approach, you can make your documentation process more efficient and focused. Simply.Coach helps you reduce administrative burdens while ensuring secure and accurate note-taking, allowing you to concentrate on what matters most: your clients.Ready to simplify your SOAP note documentation? Sign up for Simply.Coach’s free 14-day trial and schedule a demo to see how it can assist in easing your work!