Writing SOAP Notes for Therapy

Document the client’s self-reported information including feelings, thoughts, experiences, and significant statements. Note their emotional state, symptoms, concerns, issues, and any relevant history provided.

Record observable information such as the client's behavior, appearance, and speech. Assess their mood, affect, and include results from any clinical assessments or tests conducted during the session.

Analyze the gathered subjective and objective information to provide clinical impressions, note the client's progress or changes, and update or reaffirm their diagnosis. Highlight the client’s strengths and challenges.

Outline the treatment plan with specific therapeutic interventions, homework assignments, and set short-term and long-term goals for the client. Schedule follow-up sessions and define focus areas for future encounters.

These days, many therapists are using AI tools to generate their progress notes. Because notes follow a simple formula, AI can transform a summary of your session and break it into the necessary components, like Subjective, Objective, Assessment, and Plan if you're writing SOAP notes.

Ensure that each section of the SOAP note is consistently formatted in each entry to allow for quick reference and ease of understanding.

Maintain client confidentiality and privacy in all documentation and when storing SOAP notes.

Keep the notes clear, concise, and free of jargon so that they can be easily understood by other professionals who may need to review them.

Be objective in the Objective section by avoiding interpretations or assumptions and focusing only on factual and observable data.

Where applicable, collaborate with other healthcare professionals to provide a multidisciplinary approach to the client's treatment in the plan.