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Writing SOAP Notes for Therapy

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# Writing SOAP Notes for Therapy
This playbook provides a structured format for therapists to document various aspects of a mental health therapy session using SOAP notes, which include Subjective, Objective, Assessment, and Plan sections.

### Step 1: Subjective
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.

### Step 2: Objective
Record observable information such as the client&#x27;s behavior, appearance, and speech. Assess their mood, affect, and include results from any clinical assessments or tests conducted during the session.

### Step 3: Assessment
Analyze the gathered subjective and objective information to provide clinical impressions, note the client&#x27;s progress or changes, and update or reaffirm their diagnosis. Highlight the client’s strengths and challenges.

### Step 4: Plan
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.

## General Notes

### Therapy Notes with AI
These days, [many therapists are using AI tools to generate their progress notes](https://quilltherapynotes.com). 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&#x27;re writing SOAP notes.

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

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

### Clear and Concise
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.

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

### Collaboration
Where applicable, collaborate with other healthcare professionals to provide a multidisciplinary approach to the client&#x27;s treatment in the plan.