SOAP notes for therapists: the format, with an example

SOAP stands for Subjective, Objective, Assessment and Plan. It started in medicine in the 1960s and spread to almost every clinical field, counselling and psychotherapy included. The appeal is simple. Four headings make you separate what the client told you from what you saw, what you think it means, and what happens next.

That separation pays off when you read the note again in three months, or when someone else has to. A note that mixes all four together is quick to write and slow to use.

What goes in each section

Subjective

What the client reports, in their words or close to them. Mood, sleep, what has happened since the last session, what they want to work on today. A short direct quote is worth including when the exact wording matters.

Objective

What you observed. Appearance, affect, speech, how they engaged, and anything measurable such as a PHQ-9 or GAD-7 score. Keep interpretation out of this section. "Tearful when talking about her father" is objective. "Grieving" is not.

Assessment

Your clinical view. How the client is doing against their goals, what has changed, what you think is driving it, and any risk you assessed. This is the section people skip most often, and it is the one that tells a future reader why you did what you did.

Plan

What happens next. Interventions for the next session, homework you agreed, referrals, and the date of the next appointment. If you agreed something with the client, write it here so you can both check it later.

A worked example

Here is a SOAP note for a fictional client in her sixth session of CBT for low mood. It is on the long side so that each section is clear. Most real notes are shorter.

Habits that make SOAP notes better

• Write the note soon after the session. Detail fades within hours, and a note written at the end of the week turns into a summary of your impressions.
• Keep Subjective to what matters clinically. You are not writing a transcript.
• Put scores and observable facts in Objective, even when they feel obvious. They are what shows change over time.
• Always write something in Assessment, even one line. "No change, plan unchanged" is still an assessment.
• Make the Plan specific enough that you could pick it up cold. "Continue work" will not help you next week.
• Record risk every session, including when there is none. "Denies suicidal ideation" is worth writing down.

SOAP or another format?

SOAP works well when you use outcome measures and want a clear line between observation and interpretation. Some therapists find the Subjective and Objective split awkward in talk therapy, where most of the data is what the client says. If that sounds familiar, the DAP format folds the two into a single Data section and is often quicker to write.

Whichever you choose, use it every time. A client file is easiest to read when every note has the same shape.

Where to keep them

Paper and word documents work until you need to find something. It helps to keep each note attached to the session it came from, so the client's history reads in order and you can see which sessions still need a note. That is how MindMaster stores case notes. It is free for the first six months if you want to try it with your own format.