How Long Should It Take to Write a Progress Note?

For therapists wondering “how long should it take to write a progress note?” or “how long does it take to write SOAP notes?”, this article provides information on how long it takes, SOAP note examples, and more. 

Learning how to write progress notes succinctly can be a challenge for therapists. Health insurance requirements to record timely notes and the threat of clawbacks can cause therapists to feel some stress about ensuring notes are completed. But, how much time should it take to write these notes? 

Read on for the answers to commonly asked questions like “how long should it take to write a progress note?” and “how long does it take to write SOAP notes?” 

We’ve also included an overview of SOAP notes with examples, and provided tips for writing SOAP notes with limited time.

How long does it take to document client progress?

So, how long should it take to write a progress note? Unfortunately, there is no hard and fast rule here. 

A recent survey by note expert and trainer Barbara Griswold, LMFT, found that therapists seeing approximately 18 clients a week spent on average two and a half hours a week, or 10 hours a month, writing notes. This doesn’t include crisis notes, complex cases, or intake documentation, which often takes considerably longer than an average progress note. 

Like Griswold, Maelisa McCaffrey, PsyD, states that writing progress notes should take no longer than five to 10 minutes, but in some cases, up to 15 minutes. 

What are SOAP notes?

SOAP notes are a structured framework for progress notes used by healthcare professionals to document clinical encounters with clients. 

The SOAP format also serves as a cognitive aid to support clinicians in the recording and retrieving of key information about a client, such as their health status, and clinical reasoning for assessment, diagnosis, and treatment. 

The SOAP acronym stands for Subjective, Objective, Assessment, and Plan. SOAP notes may be read by other clinicians, insurance companies, and could be subpoenaed by lawyers as part of litigation proceedings. 

Information typically recorded in each section includes:

Subjective 

In the Subjective section, the therapist should include notes on the patient or client’s subjective information of their main concerns, such as:

• The presenting problem/chief complaint, including symptoms, condition, or prior diagnosis
• History of present illness including onset, location, duration, characterization, severity, and other relevant information)
• Patient history: medical, social, family, and mental health history
• Environmental factors: stressors and other relevant information
• Review of symptoms: physical, general, and psychological symptoms
• Current medications: list of all medications the client takes regularly

Objective

In the Objective section of the SOAP note, the therapist should include a record of findings from the session, such as a mental status examination, other diagnostic or assessment data, and relevant information from other providers. 

For medical providers this section also includes physical exam findings and vital signs. 

A distinguishing factor between the subjective and objective sections of a SOAP note is that symptoms are the patient’s own report, whereas objective findings may be a clinical measure from observations about appearance, mood, affect, behavior, and speech.   

Assessment

The Assessment section should include the clinician’s evaluation of subjective and objective information to make a diagnosis (including the relevant diagnosis code). 

This section will also include a summary of recent progress, the effectiveness of interventions or treatment plans, changes to the status of the presenting problems, risk and protective factors, and in some cases, a differential diagnosis (with reasoning) of potential conditions to rule out. 

Plan 

In the Plan section of the SOAP note, the clinician outlines next steps for treatment, treatment goals and objectives, interventions, medications, referrals, resources, duration of treatment, and date of next session.  

SOAP note examples

We’ve included a couple of example SOAP notes that may be helpful to better understand the context of this kind of note.

Depression SOAP note example

• Subjective: Client reported feeling depressed this week, which she thinks is likely caused by the breakup of her marriage. She explained “feeling down” since getting her divorce paperwork signed last week. She reported a history of depression during stressful times and a family history of anxiety and depression. 
• Objective: Client displayed flat affect, sporadic eye contact, and was disheveled. Her speech was slowed, with limited spontaneous movement. PHQ-9 results show loss of interest in activities, sleeping more than usual, less energy, and difficulty concentrating. However, ASQ screen and PHQ-9 indicate no suicidal ideation.    
• Assessment: The client’s report, assessment data, and measures meet a diagnosis of major depressive disorder (ICD-10 code F33.1). Client is at low risk for suicide and has social and family support. 
• Plan: Weekly therapy to process divorce, using CBT and DBT interventions to strengthen coping strategies. Suggest patient sees primary care provider to consider medication support. Client to engage in weekly activities to boost mood, such as movement and social time.

Anxiety SOAP note example

• Subjective: Client sought support for anxiety. Symptoms include feeling anxious, struggling to concentrate in college, forgetting things, and difficulty sleeping for the past two weeks, only getting a few hours of sleep at night. Client also mentioned some instances of late night drinking when he “should be studying.” He explained a history of anxiety in stressful situations, such as school-based assessments, and a family history of anxiety. He is currently approaching finals. 
• Objective: The client was appropriately dressed and well groomed. His mood was anxious with congruent affect. Speech was rapid at times but did not indicate psychomotor agitation. Thoughts were often tangential, but they were able to respond to this clinician’s questions. Client fidgeted and moved around in their seat throughout the session and had poor eye contact. However, the client was oriented x 4. Symptoms reported in session and GAD-7 reported feeling anxious, difficulty concentrating, insomnia, irritability, and restlessness. 
• Assessment: The client’s report, assessment data, and measures meet a diagnosis of generalized anxiety disorder (ICD-10 code F41.1). Ruled out ADHD with client reports of difficulty concentrating, tangential thoughts, forgetfulness, and impulsivity. Client is at low risk for suicide and reported having social and familial supports. 
• Plan: Weekly therapy using CBT and DBT interventions to strengthen coping strategies and enhance distress tolerance. Client to engage in weekly activities learned in session, movement, and meditation. Provided handout on sleep hygiene tips. 
• 

How long does it take to write SOAP notes?

So, what’s the answer to the question “how long does it take to write SOAP notes”? Overall, therapy SOAP notes should be succinct notes and take around five to 10 minutes to compose, depending on the client, complexity of their case, and whether it is their first session. 

Intake appointments gather significantly more data and include diagnosis and treatment planning. Using an electronic health record (EHR) with checkboxes, text fields, diagnosis information, and treatment planners can make that process quicker.

Tips for writing SOAP notes under a time constraint

There are numerous ways to make documentation take less time, including:

Voice dictation software 

This can help to record notes in between sessions or at the end of the day, making it easier to recall information when completing documentation.

Write progress notes in session 

During the session, jot down your notes. This means you only need to record any referrals or follow-up conversations after the session.

Use abbreviations 

Using acronyms, abbreviations, or keyboard shortcuts can reduce the time it takes to record a progress note. 

Leverage artificial intelligence (AI)

Clinicians might consider using AI tools to record the session and draft progress notes. The use of these AI tools means all clinicians  need to do is check each note for accuracy, and possibly edit it with  any additional information.

Use an electronic health record (EHR)

Most EHRs, like SimplePractice, include features that make note-taking and documentation easier to manage.  For example, SimplePractice offers treatment planners, diagnosis codes, and templates for assessments.

Keep it concise

Remember that SOAP notes are not intended to provide a comprehensive biopsychosocial report. Simply follow the SOAP framework, and be specific and brief. 

Write notes promptly

While therapists typically try to write notes within 24 to 48 hours, from time-to-time, circumstances may prevent. You may find it helpful to make a bulleted list during a session, or straight afterwards, to help with documentation later.

Use a template

If you don’t currently use an EHR or practice management system, you may find a template helpful.  For example, templates can include examples of common conditions and symptoms, which you can tailor to each specific client, incorporating any other relevant information.

Hopefully, this article answered your questions around “How long should it take to write a progress note?” and provided helpful information to make your note-taking more expedient.

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