Understanding SOAP Note Format with Tips and Examples

As a therapist, have you ever found yourself trying to document everything your client shares but struggling to keep your notes clear, concise, and useful? Do you sometimes feel like you’re missing key pieces of information in your documentation or that your notes could be more structured to help you (and your clients) move forward more effectively?

That’s where SOAP notes come in.

SOAP notes are an essential tool for keeping your records organized and effective. In this blog, we’ll break down what SOAP notes are, explore the key components, and provide you with tips, templates, and real-world examples to help you improve your documentation. Remember, as a therapist, mastering the SOAP note format can streamline your documentation and improve patient outcomes.

By the end, you’ll not only understand SOAP notes in detail but you’ll also be equipped to write them efficiently, ultimately improving client care.

The History Behind SOAP Notes

The SOAP note format wasn’t always the standard. Dr. Lawrence Weed introduced it in the 1950s as a way to improve clinical documentation and make it more systematic. His goal was to create a standardized approach towards client documentation to help you, as a therapist, provide better care and improve communication.

Weed’s system sought to make records easier to read, more comprehensive, and ultimately more useful in patient care. Today, SOAP notes are used widely in both physical and mental health fields, streamlining workflows, reducing errors, and promoting more personalized care.

They’ve basically become the gold standard for maintaining comprehensive and organized client records.

What Exactly is a SOAP Note?

A SOAP note is a methodical documentation approach used in healthcare to record and organize client information. It stands for Subjective, Objective, Assessment, and Plan –  four key sections that help therapists like you document your observations, thoughts, and plans systematically. 

It’s a tool to keep everything organized, focused, and actionable, ensuring nothing slips through the cracks. Each section serves a unique purpose:

• Subjective: The client’s perspective, including their symptoms and concerns.
• Objective: Measurable data such as vital signs and exercise/habits results.
• Assessment: Your evaluation of the client’s condition.
• Plan: A strategy for treatment and follow-up care for your client.

This structure allows for efficient, concise, and consistent notes. Together, these components provide a comprehensive snapshot of the client’s condition, which helps you make informed decisions, communicate effectively with your client and other professionals, and verify that your client is receiving the best care. 

But let’s dig deeper into each of the SOAP components and understand how you can make the most out of each section.

Why are SOAP Notes Important for Therapists?

SOAP notes are crucial for clear communication between you (as a therapist) and your clients and to provide enhanced care quality. Whether you are managing your client’s anxiety, depression, or trauma, SOAP notes ensure nothing is overlooked in your approach.

As a therapist, your primary responsibility is to provide the best care to your clients. Effective documentation through SOAP notes makes sure that you stay organized and consistent in tracking progress, interventions, and treatment adjustments. Here are a few reasons why SOAP notes are crucial:

1. Clarification of client information: SOAP notes help you summarize each session, clarifying your client’s current condition, progress, and challenges. This clarity ensures that you and other professionals involved in the care (like doctors or other therapists) are on the same page.
2. Improved communication: SOAP notes provide a clear, standardized method of communication between you and other parties involved. If multiple professionals are treating your client, these notes make it easier to share insights and maintain continuity of care.
3. Legal and ethical protection: Detailed, accurate documentation is essential for defending the care you provide in case of audits, disputes, or legal concerns. SOAP notes, being clear and thorough, aid in demonstrating the reasoning behind your treatment choices.
4. Treatment tracking: By documenting both subjective reports and objective observations, you can easily track your client’s progress over time, adjusting and modifying your treatment plan as and when needed.
5. Support client-centered care: By documenting both your client’s experiences and your professional observations, SOAP notes facilitate a client-centered approach to care. You’re not just documenting symptoms but also ensuring that the treatment plan aligns with the client’s goals and progress in the long term.

How Long is a SOAP Note?

A SOAP note is typically short and to the point, usually spanning two to four paragraphs. While its length can vary depending on the complexity of the patient’s condition, the goal is always to be thorough without unnecessary detail.

The SOAP note’s structured format promotes a comprehensive approach, guiding you to gather maximum information about your client and their treatment. Since SOAP notes are a standardized format widely used across healthcare settings, they ensure that your mental healthcare records are easily understandable by other providers, fostering seamless continuity of care for your clients.

Key Components of a SOAP Note

While it might sound simple, each section of a SOAP note plays a vital role in documentation. Let’s break down each one to ensure you’re getting the most out of your notes.

1. Subjective: Capturing the client’s voice

The subjective section is where you capture your client’s experience and what they tell you about their condition. This is not about what you observe but what the client feels, believes, or reports.

What’s included:

1. Chief complaint: Why is your client seeking treatment today? For example, “Client reports feeling overwhelmed with stress and struggling with sleep.”
2. Personal observations: How is your client feeling emotionally or mentally? For example, “Client appears anxious, fidgeting with their hands, and has difficulty making eye contact.”
3. History: Includes both medical and personal history relevant to the current session. Example: “Client has a history of generalized anxiety disorder (GAD) and reports recent stressors due to work pressures.”
4. Current symptoms: These should be described in detail, including duration and intensity. Example: “Client reports persistent feelings of nervousness, particularly before work meetings.”

Including direct quotes from your clients can be helpful, especially when they express their feelings. Phrases like “I don’t feel like I’m myself anymore” are valuable as they provide insight into your client’s emotional state and can help track their progress.

2. Objective: The facts & figures

In the objective section, you document the facts, the things you observe, measure, or test. Unlike the subjective section, which relies on the client’s perspective, the objective section is based on concrete data.

What’s included:

1. Vital signs and physical exam findings: If you’re treating someone with physical symptoms such as posture, then non-verbal cues are crucial. For instance, “The client frequently looked away during a conversation, tapped their fingers on the table, and had a tense posture.” These signs can give you important clues about how your client’s body is responding and help you provide the best care.
2. Behavioral observations: In a mental health context, these could include mood, tone of voice, eye contact, and other non-verbal cues. For instance, “Client was observed to be slumped in the chair, spoke with a soft tone, and avoided eye contact.”
3. Test results: For those using feedback and test tools, this section includes any measurable data, like psychological assessments or forms and reports or surveys conducted.

Objective information adds validity to the subjective details shared by your client and makes your documentation more robust.

3. Assessment: Making sense of the information

The assessment section is where you, as a therapist, interpret the data you’ve collected. Here, you’ll analyze the subjective and objective information to provide your professional evaluation of your client’s progress.

What’s included:

1. Diagnosis or clinical problem list: You may document the client’s current condition or diagnosis (e.g., Generalized Anxiety Disorder, Major Depressive Disorder).
2. Progress: Is your client improving? Are they regressing? For example, “Client shows some improvement in managing anxiety but continues to struggle with sleep disturbances.”
3. Differential diagnosis: If applicable, list any other possible challenges or conditions to consider for a thoroughly analyzed treatment. For instance, “Differential diagnosis includes panic disorder due to occasional shortness of breath.”

The assessment section helps both you and your client understand where things stand and assist you in informing your client about the treatment decisions going forward.

4. Plan: Mapping out the road ahead

In the plan section, you document what comes next. What interventions will you implement? How will you continue to monitor your client’s progress?

What’s included:

1. Treatment strategies: What methods or interventions will you use and implement in the ongoing sessions? For example, “Continue cognitive behavioral therapy (CBT) focusing on anxiety management techniques.”
2. Timeline and follow-ups: When should the next session occur? What progress should be seen until the next session as per the plan? For example, “Next session scheduled for one week from today should see changes in the level of stress the client experiences through the regularity of mindfulness techniques.”
3. Referrals or additional tests: If your client requires further evaluation or external help, you’ll note this here. Example: “Referral to a psychiatrist for medication management.”
4. Education and support: What can your client do outside of therapy to support their progress? Example: “Client will practice playing an engaging sport like badminton or even chess every day to take their mind off stress.”

A clear and actionable plan is crucial for guiding your client’s progress and ensures that all treatment goals are measurable and achievable. The plan section ensures that you’re not just helping your client currently but actively planning the next steps for their treatment.

Formatting Tips for SOAP Notes

While the content of SOAP notes is crucial, how you present the information also matters. Use templates as they can ensure consistency in your documentation. They provide a ready-made structure that you can easily customize for each client. Simply.Coach offers customizable templates that help you streamline your SOAP note writing, ensuring both accuracy and efficiency.

Here are some formatting tips to keep in mind:

• Use bullet points: Bullet points help break down information into digestible chunks, making it easier to read and refer to later. For example, in the assessment section, you could use bullets to list different symptoms or issues.
• Balance conciseness with detail: It’s important to be clear and concise but also thorough. Too much detail can overwhelm the reader, while too little can leave gaps in understanding. Frame precisely termed sentences with abbreviations listed in the sections below. 
• Avoid ambiguity: Be as specific as possible. For instance, instead of noting, “Client appears upset,” specify, “Client was tearful during the session and expressed feelings of hopelessness.”
• Use client quotes: Including direct quotes from your clients helps to capture their voice and provides a more accurate record of their experience. For example, documenting a client saying, “I feel like I can’t get out of bed most days,” offers clear insight into their condition.
• Plan for concise note-taking: Aim for 5 to 7 minutes to jot down your client’s progress notes after your sessions. Squeeze them in whenever possible so you’re not stuck with a backlog of notes to write by the end of the day. A little time management here goes a long way in maintaining balance in your workday.
• Quality over quantity: Focus on being comprehensive, not long-winded. It’s all about hitting the key points. Don’t overcomplicate things, but make sure you cover the essentials. If you can cover the same thing in 2 sentences with precision, try not to stretch it up to 5 sentences.
• Don’t stress over documenting every detail: While it’s important to keep detailed records, don’t worry about writing down every single thing that happened in your session. For insurance purposes, your notes should primarily support the client’s diagnosis and demonstrate the ongoing need for treatment and the approach you’re using. Focus on the bigger picture, and the critical elements will naturally fall into place.

Common SOAP Note Abbreviations

Here are some common abbreviations used in SOAP notes to streamline your documentation:

• SOB – Shortness of Breath
• ROM – Range of Motion
• PMH – Past Medical History
• ADLs – Activities of Daily Living
• C/O – Complains Of
• WNL – Within Normal Limits
• Tx – Treatment
• b/c– because
• CC– chief complaint
• cl– client
• d/t– due to
• Ed– education
• min, mod, max– minimum, moderate, maximum
• sx– symptoms
• w/, w/o– with, without

SOAP Note Example Templates

Here are some examples of a SOAP note template for your sessions. These templates will help you create comprehensive, consistent notes for each of your clients:

Blank SOAP Note template

SOAP Note Template

SOAP note template example

Enhancing SOAP Note Writing with Simply.Coach

SOAP note writing is a vital part of an effective therapy practice, offering a clear, structured method for documenting client sessions. However, the process can be time-consuming. That’s where Simply.Coach, the only HIPAA, GDPR, and SOC2-compliant therapy management software, can make a significant difference. Designed to simplify documentation and client management, Simply.Coach offers customized SOAP note templates, reducing your administrative burden and giving you more time to focus on your clients’ needs.

With Simply.Coach, you can easily create SOAP notes that follow the standard format while also tailoring them to reflect your unique therapeutic style. The platform also provides quick access to client histories, allowing you to track progress over time and stay aligned with long-term goals. Additionally, Simply.Coach supports goal-setting, progress tracking, and scheduling, all in one place.

By incorporating Simply.Coach into your practice, you’re not only simplifying the note-taking process but also improving your overall efficiency, communication, and client care. Mastering SOAP notes with Simply.Coach means enhancing the quality of your documentation while streamlining administrative tasks, leading to better client outcomes and a more organized practice.

Ready to take your SOAP notes to the next level? Try Simply.Coach by scheduling a demo or signing up for a 14-day free trial today and discover how its customizable templates and user-friendly features can transform your documentation process. 

FAQs

Q. What is in a SOAP note?
A. A SOAP note includes four key components: Subjective, Objective, Assessment, and Plan. The Subjective section captures the client’s own words, while the Objective part includes observable data and clinical findings from you, the therapist. The Assessment evaluates the client’s progress, and the Plan outlines the next steps in treatment.

Q. Are SOAP notes still used?
A. Yes, SOAP notes continue to be widely used in therapy today as an essential tool for documenting client progress. They serve as an effective way to communicate between you (the therapist) and other healthcare professionals, helping track treatment outcomes, identify areas for improvement, and ensure coordinated care. Their standardized structure makes it easier to reference and review client histories over time.

Q. What is the alternative to SOAP notes?
A. BIRP notes and DAP notes are alternative documentation formats you can use. BIRP notes focus on documenting behavior, intervention, response, and plan, which is helpful when focusing on specific treatment strategies. DAP notes, on the other hand, focus more on accounting data, assessment and planning of the client’s progress, allowing for a deeper reflection on the client’s emotional and behavioral changes during therapy sessions.

Q. How long should a SOAP note be?
A. Typically, a SOAP note is concise, ranging from two to four paragraphs. However, the length may vary depending on the complexity of the client’s condition or the session. The goal is to be thorough yet succinct, ensuring that the note captures all relevant details while remaining efficient and readable for future reference.

Q.How to write the Subjective in a SOAP note?
A. The Subjective (S) section is where you document what the client shares about their thoughts, feelings, and experiences, including any relevant history. This could involve their current state, challenges, or goals, as well as personal circumstances that could affect therapy, such as home life or previous medical history. It’s important to listen actively as a therapist yourself and capture the client’s perspective accurately, as it provides key context for the therapeutic process.