SOAP notes are a structured method widely used in mental health documentation. Originally developed in medical settings, the SOAP format has become a gold standard for clinical note-taking in psychotherapy because of its clarity, consistency, and comprehensive nature.

Each note you write is divided into four distinct components—Subjective, Objective, Assessment, and Plan—helping to clearly document each session, track client progress, and ensure effective communication among care providers.

This article provides a practical guide to writing effective SOAP notes, complete with best practices, common pitfalls to avoid, and a real-world example to reference.

Key Components of SOAP Notes

Let’s begin by clearly defining each of the four sections in the SOAP format:

1. Subjective (S)

This captures the client’s own perceptions, experiences, feelings, or concerns as reported during the session. In the client's own voice, include presenting issues, symptoms, emotional states, and directly quoted statements when relevant.

Always clearly attribute opinions or feelings to the client to prevent mixing in your clinical interpretations.

Example of Subjective Section:

"I'm feeling anxious and not sleeping well." (Client’s own words)

2. Objective (O)

This includes observable, factual, measurable data collected by the clinician. Document observable behaviors, mood and affect, appearance, insight, or orientation noted throughout the session.

🚫 Avoid interpretations or assumptions in this section—focus strictly on evidence-supported observations.

Example of Objective Section:

"Client entered the session pacing; continued fidgeting and crumpling paper throughout session."

3. Assessment (A)

Here, clinicians interpret and analyze subjective and objective data, offering clinical insights.

• Discuss progress toward therapeutic goals

• Note symptom changes

• Consider potential diagnoses

• Offer clinical insights or hypotheses

🚫 Avoid merely repeating earlier points—instead, synthesize and analyze the available data, clearly explaining why you arrive at these interpretations.

Example of Assessment Section:

"Increasing anxiety related to workplace stress, demonstrating difficulty communicating effectively. Moderate anxiety symptoms observed, indicated by restless behavior and self-reported worries."

4. Plan (P)

Outline the next therapeutic steps clearly and concretely.

• Document specific interventions

• Assign homework assignments

• Note session frequency

• Include future topics to address

• Record referrals or medication evaluations (if applicable)

Each plan should logically follow the assessment and directly connect to overarching treatment goals.

Example of Plan Section:

"Role-play conflict resolution strategies next session; client to practice daily body-scan meditation and lunchtime walks for anxiety reduction."

Step-by-Step Writing Guide for SOAP Notes

Follow these clear, practical steps for consistent SOAP note documentation:

Step 1: Document Immediately

To ensure accuracy, complete SOAP notes immediately or soon after the session concludes, using brief session notes as memory prompts.

Step 2: Separate Subjective and Objective Clearly

• Document exactly what the client says in their own words (Subjective).

• Record observable behaviors, appearance, or affect (Objective).

Step 3: Analyze and Interpret

• Reflect on the session’s data, connecting subjective concerns with observable signs to formulate your clinical assessment.

• Note any shifts in diagnosis or symptom severity.

Step 4: Develop an Actionable Plan

• Outline explicit interventions or homework tasks.

• Show the connection to therapeutic objectives.

• Update or revise previous plans if necessary.

Example SOAP Note

Here’s an example of a brief, accurate SOAP note for psychotherapy:

S:
"They don’t appreciate how hard I’m working." (Client reports feeling undervalued at work.)

O:
"Client entered session pacing and with clenched fists; later sat but continued fidgeting and crumpling a piece of paper."

A:
"Work stress and frustration contributing to increased anxiety. Client struggles with communication skills at work and requires assertiveness training and stress management techniques."

P:
"Next session will involve role-playing conflict resolution scenarios. Client to practice body-scan relaxation daily and take lunchtime walks to manage stress."

Pro Tips and Best Practices for SOAP Notes

Follow these best practices to ensure clarity, compliance, and effectiveness in your documentation:

✅ Document in a timely and consistent manner – Write SOAP notes as soon after the session as possible to maximize accuracy and completeness.

✅ Be concise yet specific – Avoid vague terminology or excessive detail. Specify clear, observable behaviors and clearly articulated client perspectives.

✅ Incorporate the client's own words appropriately – Use direct quotes sparingly to highlight impactful statements, bringing authenticity to your note.

✅ Maintain clear boundaries between sections – Clearly distinguish subjective experiences from objective observations to provide evidence-based assessments.

✅ Regularly update assessments and plans based on client changes – Ensure each session’s Plan reflects the client’s current clinical status and treatment objectives.

Common Mistakes to Avoid in SOAP Notes

🚫 Including unsubstantiated opinions – Avoid writing impressions such as "client is in denial" without clear evidence or direct client statements.

🚫 Using vague language – Statements like "client is better" are unclear. Instead, precisely describe tangible improvements, noting measurable progress.

🚫 Unnecessary repetition between sections – Each section has a unique purpose; avoid duplicating identical information across Subjective, Objective, and Assessment sections.

🚫 Neglecting to update session Plans – Regularly revise your Plan section to address changes in client needs or therapeutic direction.

🚫 Delayed documentation – Waiting too long can cause inaccuracies and incomplete notes, negatively affecting continuity of care.

Conclusion

SOAP notes are a foundational component of psychotherapy documentation.

When written skillfully, they:
✔️ Clearly convey each session’s essential information
✔️ Demonstrate therapeutic progress
✔️ Ensure continuity of care

By consistently integrating the best practices highlighted here and avoiding common documentation pitfalls, you’ll produce professional, clear, compliant SOAP notes that support successful treatment and care coordination within your mental health practice.

Adapt this SOAP note framework to fit your unique clinical setting, ensuring each note concisely captures session-critical information and aligns with evidence-based professional standards.