Generate SOAP Notes (Behavioral Health)

Last updated: Nov 2025

Generate SOAP notes from a recorded or live session—then review, finalize, and auto-fill your EHR using the Nudge Chrome extension.

Who this helps

• Therapists, counselors, psychologists

• Group practices standardizing documentation

• Admins reducing copy-paste and template errors
  
  

What you get

• Structured Subjective, Objective, Assessment, Plan

• Carry-forward of diagnosis, goals, and prior response

• Redaction and formatting controls (bullets or paragraphs)

• EHR Copilot to map sections into the right fields
  
  

How it works with your EHR

Capture a session in Nudge (or upload audio). Your SOAP draft appears with clear S/O/A/P sections. Open a new note in your EHR, launch the Nudge extension, pick the client and note type, and confirm the field mapping (edit-before-save). No API keys or IT projects required.

Quick example

Anxiety follow-up (GAD-7):

• Subjective: patient reports sleep disruption, situational triggers.

• Objective: GAD-7 score, affect, speech, mental status.

• Assessment: symptom course, risk screen, Dx continuity.

• Plan: CBT homework, coping skills, next appointment; treatment plan goals referenced.
  
  

Results (2025)

SOAP note ready in < 60 seconds after capture.
Typical teams report 4–6 hrs/week saved on documentation.
Cleaner, more consistent notes across clinicians.

FAQs

Can I force bullet points in S/O/A/P?
Yes. Choose bullets or paragraphs per note type, and save those preferences team-wide.

Does it support DAP/BIRP/GIRP formats?
Yes. Pick your preferred structure at generation; you can switch per client or per team policy.

Will it include medical necessity language?
Yes. The Assessment/Plan can include justification and continuity language; you can edit before finalizing.