Postpartum depression handout
Summary
Knowing how to write a SOAP note using the standard format (Subjective, Objective, Assessment, Plan) helps clinicians document and track client care.
The Subjective section captures client-reported symptoms and history, while the Objective section records physical findings like vital signs and appearance.
The Assessment section interprets findings to reach a diagnosis.
The Plan section outlines treatment, goals, and follow-up expectations.
Learning how to write SOAP notes with these best practices ensures timely documentation, clear language and HIPAA compliance, while avoiding subjective opinions or irrelevant details.
What’s a SOAP note?
Knowing how to write a SOAP note is incredibly useful. The SOAP template helps clinicians capture the information needed for clear, efficient, and effective record keeping.
SOAP stands for Subjective, Objective, Assessment, and Plan. Each letter refers to one of four sections in the document you will create with your notes.
While the specific details and length of SOAP notes may differ across clinical fields, the underlying structure remains consistent. Since the format is standardized, mastering how to write a SOAP note can help providers across different specialties easily interpret your documentation, simplifying the process of coordinating care for your clients when necessary.
In this article, we’ll cover how to write SOAP notes, describing the SOAP format and what to include in each section. We’ve also compiled some SOAP note examples, including SOAP notes examples for social workers and therapists, to help you get started in keeping session notes and streamlining your note-taking process.
How to write a SOAP note
Learning how to write SOAP notes is generally a straightforward process because it always follows a specific and precise structure. However, it does take some practice.
Each letter in the SOAP acronym represents one of the following four primary headings:
Subjective
Objective
Assessment
Plan
Specific documentation within each section varies based on your clinical field, the individual client, and the focus of your shared work.
We outlined the structured approach to how to write a SOAP note and suggestions for what to include, based on a synthesis of peer-reviewed research found in StatPearls.
Subjective
This section is for subjective reporting of how your client says they are feeling during the session and what they report about their current symptoms. It can also contain information gathered from family members and reviews of past medical records.
Many mental health practitioners focus on what’s known as a “Chief Complaint” (CC) or the presenting problem in this section. Even if the client reports multiple CCs, it’s important to try to identify the most compelling problem so that you can ultimately provide an effective diagnosis.
Some general areas of inquiry as you try to identify the primary CC may include: history of present illness, medical history, review of systems, and current medications.
Here are some questions to ask to help uncover your client's Chief Complaint:
Describe your symptoms in detail. When did they start and how long have they been going on?
What is the severity of your symptoms and what makes them better or worse?
What is your medical and mental health history?
What other health-related issues are you experiencing?
What medications are you taking?
Make sure any opinions or observations you include in the section are attributed to who said them—whether it’s yourself or your client. Because this is a subjective section, you don’t want to pass off any of this information as fact.
Objective
The objective section should be made up of physical findings gathered from the session with your client.
Some examples of SOAP charting for this section include:
Vital signs
Relevant medical records or information from from other specialists
The client’s appearance, behavior, and mood in session
Note: This section should consist of factual information that you observe and not include anything the patient has told you.
Assessment
The assessment section combines all the information gathered from the subjective and objective sections. It’s where you describe what you think is going on with the patient.
You can include your impressions and your interpretation of all of the above information, and also draw from any clinical professional knowledge or DSM-5 criteria/therapeutic models to arrive at a diagnosis (or list of possible diagnoses).
Plan
The last section of your SOAP note should outline your plan for next steps to treat the patient, including short- and long-term goals for your patient. Be specific about what you plan to work on in the next session or in general and your expectations for the duration of treatment.
Can ChatGPT write SOAP notes?
Yes, you can use LLMs like ChatGPT or Claude to draft your SOAP notes—but keep in mind that these are strictly drafts, and you’ll need to thoroughly review the notes to ensure accuracy. You also cannot input anything involving protected health information (PHI) into LLMs to remain HIPAA-compliant.
Another option: Consider using vetted tools integrated into your EHR, like SimplePractice’s AI Note Taker, to get started with your SOAP notes.
State board regulations around documentation may vary, so always confirm your state's regulations before proceeding.
Therapy SOAP note example
If you’re looking for an example for writing SOAP notes for therapy, here’s a SOAP note example that may help behavioral health practitioners better understand how to write a SOAP note.
Subjective
Client reports feeling more anxious this week. She said she felt more jittery and on-edge, and reports having more anxious thoughts that were harder to control.
Objective
During the session, the client was fidgety, wringing her hands, and speaking quickly. She appeared to have difficulty concentrating and asked me to repeat questions multiple times before responding. Client described a fear of losing her job and her housing, though admitted she didn’t have any evidence those events were imminent.
Assessment
Based on the client’s reports and in-session observations, the client’s anxiety has increased but continues to meet criteria for generalized anxiety disorder (GAD).
Plan
Recommended that client see a primary care physician to rule out any thyroid or other medical condition. Client will continue coming to therapy once a week for the foreseeable future to treat anxiety through cognitive behavioral therapy (CBT). Also recommended that the client try meditation and other mindfulness techniques at home in between sessions.
Sample SOAP note for depression
For clinicians looking to evaluate different clinical presentations, here is a sample SOAP note for depression to demonstrate how somatic symptoms and cognitive distortions are effectively tracked.
Subjective
Client reports feeling "heavy and exhausted" over the past week, stating they struggled to get out of bed most days. Describes mood as a "3/10." Expresses feelings of worthlessness regarding their performance at work, noting, "I'm letting everyone down." Denies active suicidal ideation but reports passive thoughts of "wishing I could just sleep for a long time."
Objective
Client arrived on time for the telehealth session. Appearance was uncharacteristically disheveled; posture was slumped with minimal eye contact. Speech was slow and monotone. Affect was flat and congruent with reported depressed mood. Cognitive processing appeared delayed when responding to prompts.
Assessment
Client is exhibiting an exacerbation of symptoms consistent with Major Depressive Disorder (MDD), recurrent, moderate. The increase in somatic symptoms (hypersomnia, psychomotor retardation) and pervasive negative cognitions suggests a recent situational stressor at work has triggered a depressive episode. Client demonstrates fair insight but impaired coping efficiency at present.
Plan
Safety: Collaboratively reviewed and updated the client's crisis safety plan; client agreed to utilize coping contacts if passive thoughts shift to active intent.
Intervention: Used cognitive behavioral therapy (CBT) to identify and challenge automatic negative thoughts related to work performance. Introduced a behavioral activation schedule to target hypersomnia.
Next steps: Scheduled next individual session for next week.
Homework assigned: Complete behavioral activation log for at least one small daily task.
SOAP note example for speech-language pathologists (SLPs)
Speech-language pathologists (SLPs) also need to know how to write SOAP notes, as SLPs use the SOAP format to capture clinical information about client visits, current assessments, and outcomes.
Here’s sample SOAP charting copy an SLP might use for a SOAP note:
Subjective
The client reports increased vocal demands since the last meeting due to additional meetings at work. She notes her colleagues commented “Your voice is back!” after her last work presentation, but that she still experiences intermittent vocal fatigue during social events. She reports she has been incorporating her semi occluded vocal tract straw (SOVT) routine three times a day for five minutes.
Objective
Led the client through SOVT exercises with a straw in water. Client independently achieved optimal voicing in 5/5 opportunities. Introduced conversational training therapy (CTT) where client differentiated between her “husky” voice and her “presenter” voice in 5/5 opportunities. Practiced functional phrases where client achieved “presenter” voice in 8/10 opportunities with moderate visual cues. The client’s vocal effort using CTT was 4/10.
Assessment
The client met goals of optimal voicing to meet vocational demands, as evidenced by an improvement from vocal effort of 7/10 (“somewhat hard”) to 4/10 (“somewhat easy”). She is pressing toward carryover of SOVT strategies to meet social demands.
Plan
Continue the current plan of care. Target optimal voicing in functional environments with CTT techniques. Introduce additional compensatory strategies to manage vocal load across vocational and social settings.
SOAP notes example for social workers
Social workers use SOAP notes to document client progress, justify services, and create records that may be reviewed by courts, housing authorities, or other agencies. Here's a SOAP notes example for social workers managing a case involving housing instability and mental health.
Subjective
Client reports she was served an eviction notice this week and states, "I don't know where we're going to go." She expresses significant distress about her two children's stability and school attendance. Reports she has not been sleeping and describes her anxiety as "through the roof." States she has not yet contacted the housing assistance program discussed in the previous session due to feeling "too overwhelmed to make calls."
Objective
Client arrived on time to the in-person session. Appeared visibly distressed—eyes red, tissue in hand. Speech was pressured when discussing the eviction but slowed when redirected. Children were present briefly at the start of session and appeared appropriately groomed and interactive. Client maintained engagement throughout and demonstrated adequate receptive comprehension of resources provided.
Assessment
Client is experiencing acute psychosocial stressors consistent with housing instability, which are exacerbating existing anxiety symptoms. Avoidance behavior (failure to contact housing program) is consistent with anxiety-driven coping patterns. Children appear stable at present, though continued housing instability poses risk to their educational continuity and wellbeing. Client demonstrates motivation for change but requires concrete support to navigate systems.
Plan
Provided client with direct contact information for two emergency housing assistance programs and offered to place the initial call together during session; client agreed. Will follow up with the client's children's school social worker to flag potential attendance disruption. Scheduled follow-up session for next week to review housing application status and reassess anxiety symptoms. Client will complete one housing program application before next session using the pre-filled template provided.
How to use SOAP notes with your practice management system
SimplePractice is the HIPAA-compliant practice management software with easy and secure therapy notes, progress notes, SOAP notes, and other note-taking templates built into the platform. This makes it fast and simple to access your notes and fill them out after each session.
With built in templates for SOAP notes in the SimplePractice software, you’ll never find yourself searching for instructions for how to write SOAP notes ever again. SimplePractice makes it easy for you to get more organized and run a fully paperless practice.
If your EHR doesn’t have built-in SOAP notes, you can download our free SOAP note template to keep on hand, or make your own following the guidelines we provided above.
Remember, SOAP notes are meant to document your findings in a way that’s easy to record and refer back to. Consequently, you should use the format that makes the most sense for your practice.
If you’ve been considering switching to a fully integrated, HIPAA-compliant practice management software, SimplePractice gives you everything you need to streamline your note-taking process.
You can pull a SOAP note template from our robust template library, use our “load previous note” feature to easily update your notes each session, and send follow-up information about your sessions to your clients through the client portal.
Sources
Podder, V., Lew, V., & Ghassemzadeh, S. (2023). SOAP Notes. StatPearls.
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