How to Write SOAP Notes (With Examples)
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Wondering how to write SOAP notes? The SOAP format can be one of the most effective ways for clinicians to document and objectively assess, diagnose, and track plans for clients.
Knowing how to write SOAP notes is incredibly useful. The SOAP template helps clinicians capture the information needed for clear, efficient, and effective record keeping.
In the SOAP format, 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.
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 to help you get started in keeping session notes and streamlining your note-taking process.
What’s a SOAP note?
According to the journal Academic Medicine, the SOAP format was developed in the 1950s by Lawrence Weed, a professor of medicine and pharmacology at Yale University.
Originally referred to as a problem-oriented medical record (POMR), the SOAP note evolved, and today it’s widely used by practitioners across many healthcare disciplines—including mental health professionals—to document and organize findings in an objective way.
Though the specific information and length of these documents varies by discipline, it’s important to learn how to write SOAP notes because they all follow the same basic structure. This standardization is easily recognizable by providers in other specialities—making it easy to coordinate care for your clients if needed.
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.
SOAP notes include four headings that correspond with each letter of the acronym:
- Subjective
- Objective
- Assessment
- Plan
The notes and records you enter under each heading will depend on your clinical specialty, who your client is, and what you’re working on during your sessions together.
We’ve broken down the order of how to write SOAP notes and provided suggestions for what to include in each section as recommended by a review of peer-reviewed articles 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 SOAP notes 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.
Therapy SOAP note example
If you’re looking for an example for writing SOAP notes, here’s a SOAP format example that may help behavioral health practitioners better understand how to do 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.
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.
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.
Used by over 200,000 clinicians nationwide, SimplePractice is consistently rated as the very best practice management software for therapists, speech-language pathologists, occupational therapists, and other practitioners in the health and wellness industry.
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Related reading
Sources
- Academic Medicine. (2019). Remembering Lawrence Weed: A Pioneer of the SOAP Note.
- StatPearls. (2023). SOAP Notes - StatPearls - NCBI Bookshelf.
- SimplePractice. (2021). The Evolution of the SOAP Note.
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