How to Write the SOAP Note Assessment Section

In this article, we’ll review what needs to be included in the SOAP note Assessment section, including tips and examples of SOAP Assessments.  

It is important for clinicians to be familiar with the requirements of the SOAP note Assessment section in order to correctly write a SOAP note. 

The SOAP note is one of the most widely used formats of documentation across multiple sectors of healthcare, helping to better standardize documentation. It also improves client recordkeeping, coordination of care, insurance reimbursements, and liability protection. 

SOAP notes include four sections, and their titles create the SOAP acronym: Subjective, Objective, Assessment, and Plan. 

If you’re wondering how to write a SOAP note, the SOAP Assessment section follows the Subjective and Objective sections. It serves as a clinical synopsis of those previous two portions of the note. 

What is the Assessment part of a SOAP note?

This third section in a SOAP note—the SOAP note Assessment section—brings together the information provided in the previous two sections and presents a summary from the vantage point of the clinician. 

The SOAP note Assessment involves using clinical judgment and analysis to provide a combined synthesis of the Subjective and Objective sections. This is where the clinician will interpret the self-reports of the client and the empirical data.  

The SOAP Assessment is also where clinicians should record clinical themes, diagnoses, applied interventions, and progress of the client, with specificity.

What goes into the Assessment part of a SOAP note?

Clinical themes and problems

This portion should not merely be a repeat of the client’s reported symptoms. Instead, it should include the challenges that the client is having from the therapist’s clinical point of view.  

This section requires an analysis of the Subjective and Objective sections to discern the client’s true underlying issues. 

In the SOAP note Assessment section the therapist can highlight specific functional impairments on the client’s life, which are caused or exacerbated by the noted issue(s). 

If there are multiple problems, the clinician would describe how those problems might interact with one another. 

For example,  a client might complain about a lack of relationships in their life. The therapist, however, may have enough information about the client’s other symptoms and past history to document that the client has lost connection with three close friends in the past year because they display self-protective behaviors as a result of complex childhood trauma. 

When completing the SOAP Assessment, it is important to be as specific as possible—describing the problems, impairments, and associations with the client’s specific diagnoses in detail. This is particularly important for insurance reimbursements, as these are the  criteria that insurance companies are looking for.  

Diagnoses

For clients with an established history, the Assessment section should encompass all diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) or International Classification of Diseases, Tenth Edition (ICD-10). 

In cases involving new clients or diagnostic uncertainties, clinicians should outline potential differential diagnoses that necessitate further consideration. 

This diagnostic work should be backed up by the information provided in the Subjective section, the Objective section, and any previous documentation on the client. 

Interventions

In the SOAP note Assessment section, it is essential for clinicians, particularly those being reimbursed by insurance companies, to highlight the evidence-based interventions being applied. 

Based on the problems, diagnoses, and goals of the client, clinicians should develop a treatment plan that includes evidence-based interventions that the clinician is providing to help the client reach their goals. These can be interventions that have been applied over time, or interventions applied in the session that the note is being written for. 

Although necessary for quality therapy, most insurance companies do not consider practices like reflective listening or validation to be evidence-based therapeutic techniques.  

Instead, insurance payers are looking for statements such as, “the Writer utilized CBT to reduce cognitive distortions” or “Writer utilized EMDR Phase 4 reprocessing to reduce intrusive memories.”  

A clinician should never miss an opportunity to highlight a modality they are trained in. 

For example, if a therapist used dialectical behavioral therapy (DBT) interpersonal effectiveness skills while assisting a client in communicating their emotions, it is more beneficial to name the specific DBT skill employed than to state that the therapist worked on communication skills during the session. 

Client progress

This part of the SOAP note Assessment should include any changes with the client’s status and their response level to interventions provided. 

Clinicians should note progress, regression, or lack of change as specifically as possible, with reference to the treatment plan. 

Attempting to be as measurable as possible here is helpful. For example, rather than stating the client’s “anxiety has reduced,”a clinician can write that “the Client’s worry about work conflict has reduced, improving their average hours of sleep to seven per night.”

How to write the Assessment in SOAP notes

When writing a SOAP note, it can be helpful for the clinician to think about taking on different roles. 

For the Subjective section, for example, the clinician can view themselves as an interviewer or reporter who is trying to accurately represent the client’s point of view. 

For the Objective section, clinicians can view themselves as scientists reporting their impartial discoveries about the client.  

When thinking about how to write Assessment in SOAP notes, clinicians can fully put on their therapist hat and utilize their clinical knowledge and skills.  

The focus of the Assessment section is to synthesize information from other sections, interpret information, make clinical determinations, note interventions used, track client progress, and formalize all of this information into a brief, coherent summary.  

When writing the SOAP Assessment section, it can be helpful to answer the following questions:

• Which clinical themes are present?
• What diagnostic criteria are being met by the client? 
• Are there any differential diagnoses that should be noted for further assessment?
• What interventions have been utilized and how has the client responded?
• What progress or lack of progress has the client made toward their self-determined goals?

SOAP note Assessment examples

Example #1

Client experiences symptoms congruent with a social anxiety disorder diagnosis. 

Her frequent worry about the judgment of others in social settings causes her to have infrequent interactions with others and to often skip in-person classes for school. Panic disorder and agoraphobia still needs to be ruled out, as she has experienced panic attacks in the past and has some fear of those symptoms returning.  

She has increased her attendance of school classes from zero visits to two visits per month since beginning cognitive behavioral therapy (CBT) in-vivo exposure treatment. She is better able to identify her cognitive distortions that feed her social anxiety, however, she still struggles with catastrophic thinking when planning social interactions. 

Writer utilized CBT worksheets as Writer and Client reviewed her exposure homework since last session, including her levels of distress during the exposure activities. She was able to complete three out of the four exposure steps for homework. 

Writer worked with her to develop her exposure plan for the following week, and introduced the DBT distress tolerance TIPP skills that she can utilize when feeling overwhelmed. 

She was receptive to the intervention, as evidenced by her engagement with the exercises during the session.

Example #2

Client meets criteria for post-traumatic stress disorder (PTSD) after witnessing an assault and armed robbery two months ago.  

Their intrusive memories and nightmares have limited their sleep to an average of three hours per night. Their extreme hypervigilance has impaired their ability to concentrate and listen to their partner. 

This has led to increased conflict in the relationship and four reported volatile arguments in the past month. 

The Client has been vulnerable and shared their experience openly during initial sessions. 

In line with the Client’s goal to reduce their intrusive and hyperarousal symptoms, Therapist provided psychoeducation on trauma and the nervous system. Therapist also taught the Client diaphragmatic breathing. 

When applied in session, the Client was able to reduce their Subjective Units of Distress Scale (SUDS) from 9 to a more manageable SUDS of 6. The Client felt encouraged by this shift in distress levels. Writer recommended Client practice this exercise daily over the next week.  

When applying these recommendations to the SOAP note Assessment section, therapists should feel empowered to trust their training and their own clinical judgment. 

The SOAP note Assessment section gives the best overall summary about a client. Following these guidelines can help to better track a client’s journey, communicate to collaborating providers, protect liability, and provide a higher likelihood of insurance reimbursement.  

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

Try SimplePractice free for 30 days. No credit card required.

READ NEXT: 

• • How to Get the SOAP Format Right