How to Write SOAP Notes for Mental Health Counselling (In-Depth Workflow + Examples)

Therapists use standardized therapeutic progress reports, or SOAP notes, to correctly and reliably document counselling sessions. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each part captures a certain aspect of the session. In compliance with medical documentation rules, using SOAP notes ensures that records are complete, well-organized, and allow for treatment continuity.

What Is a SOAP Note in Mental Health Counselling?

Therapists document each session using a SOAP note, which is a methodical progress report format. It ensures that the professional appraisal, objective observations, subjective experiences, and the following strategy are all documented correctly. This design makes it easy to read and distribute notes.

For example, the Subjective section includes the client’s statements and symptoms, and the Objective section comprises quantitative observations. These are addressed in the Assessment section, and the Plan outlines what happens next.

• Subjective: Client’s own report of feelings, symptoms and concerns.
• The purpose is to make factual and quantitative observations.
• Assessment: Based on S and O, the doctor makes a clinical judgment or diagnosis.
• Plan: Treatments provided and recommended next steps.

The client’s medical record includes therapy SOAP notes, which are regarded as progress notes. This implies that they must follow clinical guidelines and be available to insurers and other providers upon request.

Why Do Therapists Use SOAP Notes?

Counsellors can use SOAP notes to preserve accurate and consistent records of every session. They help caregivers communicate with one another and defend their treatment to others.

Using an established framework, therapists guarantee that no critical information is overlooked. To assess progress, for example, individual symptoms and test results might be tracked in Objective.

• Maintaining a consistent format keeps essential facts from being overlooked.
• Thorough SOAP notes are used as official medical records. They support billing and demonstrate medical necessity.
• They maintain track of their customers’ progress over time, which aids in therapeutic planning.
• Other physicians can easily comprehend the problem after reading a SOAP note.

SOAP notes provide legal protection for therapists by prioritizing evidence-based observations above narrative tales. Clients and auditors can check well-written notes as needed.

What Are the Components of a SOAP Note?

A complete SOAP note has four parts:

1. Subjective: Client’s self-reported symptoms, concerns, feelings. Often includes direct quotes.
2. Objective: Clinician’s observations and measurable data. This could be mood, appearance, test results, or vital signs.
3. Assessment: Clinician’s interpretation or diagnosis combining S and O. For example, “Major Depressive Disorder” or “Progress toward goal X.” It may also note changes since the last session.
4. Plan: Interventions and subsequent actions. All interactions with the client, including assignments, follow-up sessions, referrals, and therapeutic approaches, should be recorded.

This is an example of a simple table for a SOAP note template:

Section	What to Document
Subjective	Client-reported symptoms, mood, quotes (chief complaint)
Objective	Observable facts: appearance, behaviour, test scores
Assessment	Clinical interpretation: diagnosis, progress, clinical impressions
Plan	Treatment plan: interventions, referrals, homework, next session

This table format can be used as a quick checklist when writing notes.

How to Write SOAP Notes: Step-by-Step Workflow

You can complete SOAP notes more quickly and precisely if you follow a set procedure.

1. Prepare for the meeting. Review the client’s data as well as the therapeutic goals. Check that the note template is open in your notepad or EHR. Fix client identifiers before the session. This preparation helps you concentrate on the client and saves time later.
2. Record during the discussion: As the discussion progresses, make quick notes under each SOAP category. Write down key quotes or complaints in Subjective, and note observable cues under Objective. You can use shorthand or bullet points to stay engaged. Concentrate on gathering quotes and information rather than attempting to make whole remarks in real time.
3. Immediately compose the assessment and plan. As soon as possible, complete the Assessment and Plan. Summarize the significance of the facts in the assessment. List the interventions utilized during the session, assignments, recommendations, and future steps in the plan. Completing the message in 24 to 48 hours is ideal.
4. Verify completeness and compliance: Before signing, ensure that all sections are present and designated. Make sure your words are clear and precise. Avoid using jargon and acronyms that others may not comprehend. Write comprehensive sentences so that others can read and understand the session. Check that nothing sensitive meant for private psychotherapy notes is in the progress note. Finally, date and sign the note according to your policies.

Quick Tips:

• Write in the third person and in the past tense.
• Focus more on facts and observations than on views.
• Make use of person-first language.
• Make the note brief but comprehensive.

Related: 5 Easy Steps to Create Customized SOAP Notes within Vozo EHR (Step-by-Step)

SOAP Note Template for Mental Health Counselling

A SOAP note template can streamline your writing. Many EHR systems allow you to use a template with pre-labelled sections. An example mental health SOAP template might include prompts like:

• Subjective: The main grievance, mood, eating, sleep patterns, substance abuse, etc.
• Objective: Vital signs, rating scales, speech, behaviour, appearance, and affect.
• Assessment: The assessment process includes diagnosing, interpreting symptoms, tracking target progress, and evaluating safety risks.
• Plan: Homework assignments, medication adjustments, referrals, treatment plan updates, coping skills education, interventions, and the date of the next session.

Consistency is ensured by using templates.

For instance, BehaveHealth notes that EHRs can auto-fill dates and pull in treatment goals, letting you focus on the content. Even a simple bulleted template in a Word doc can remind you of required fields.

Related: How to Build and Use Specialty Forms in Your EHR Without IT Help

SOAP Note Examples in Therapy Sessions

Concrete examples illustrate how SOAP notes look in practice. Here are three example cases from mental health counselling:

Anxiety (Generalized Anxiety Disorder)

• Subjective: The client claims to have difficulties sleeping, racing thoughts, and feeling “very anxious” every day. They state, “I can’t focus and worry all night.”
• Objective: The client is upset and speaks quickly yet clearly. 16 is the GAD-7 score. No delusions.
• The examination is for moderate generalized anxiety disorder. Work-related stress appears to exacerbate anxiety. The client struggles with coping mechanisms but shows insight.
• Plan: The lesson included diaphragmatic breathing and relaxation techniques. Exercise and relaxation journals were assigned daily. There is no medication change. Follow up in one week to evaluate improvement.

Depression (Major Depressive Disorder)

• Subjective: The client reports feeling “down” much of the day for the past two weeks, with low energy and insomnia. “I just want to stay in bed,” they report. Admits fleeting “thoughts of being better off gone” but no intent.
• Objective: Appearance dishevelled, poor eye contact. Affect flat; slowed speech. PHQ-9 = 18. Concentration is poor on a brief task.
• Assessment: Major Depressive Disorder, moderate. No immediate safety risk (no plan or intent for suicide). Depression is likely linked to recent job loss.
• Plan: Reviewed safety plan and crisis resources. Encouraged appointment with psychiatrist for medication assessment. Provided CBT activity scheduling worksheet. Set a goal for the client to rejoin one social activity this week. Next session in 3 days for close monitoring.

Trauma (PTSD)

• Subjective: The client reports recurrent flashbacks and nightmares from a previous traumatic experience. “I feel terrified when I hear a loud noise,” they tell me. Panic caused me to sleep only around 4 hours per night. Denies current suicidal thoughts.
• Objective: Client looks anxious, scanning the room. Affect anxious, voice quiet. PCL-5 score = 55. No substances noted.
• Assessment: Post-Traumatic Stress Disorder, severe. Trauma symptoms impair daily functioning. Client engaged in the EMDR technique; showed moderate distress.
• Plan: Continued EMDR processing in session. Assigned grounding techniques. Consulted a psychiatrist about PRN medication for nightmares. Follow-up in 1 week for EMDR continuation. Provided crisis contacts.

SOAP notes can be adapted for a variety of therapy scenarios, including couples counselling, adolescent therapy, substance use treatment, group therapy, and so on. The format stays unchanged, but the material in each section reflects the details of the case.

SOAP Notes vs DAP vs BIRP: Which Format to Use?

SOAP is one of several note formats. Others, like DAP and BIRP, are also common in mental health. There’s no single “best” format; each has uses:

• SOAP: The classic four-part structure is used widely. It’s thorough and familiar to many.
• DAP: Combines subjective and objective into one “Data” section, then has Assessment and Plan. It can be more concise.
• BIRP: Used often in community mental health and residential settings. It explicitly documents observed Behaviour and your Intervention separately, then the client’s Response and Plan. This format highlights medical necessity.

Format	Structure	When to Use
SOAP	Subjective, Objective, Assessment, Plan	General therapy settings; medical records.
DAP	Data, Assessment, Plan	Outpatient therapy for quick notes.
BIRP	Behaviour, Intervention, Response, Plan	Community or behavioural health.
SOAP	Progress notes vs separate private notes.

Many recent EHRs allow you to select or swap formats. Use whatever works best for your workflow, and always tie notes back to treatment goals.

Common Documentation Mistakes to Avoid

1. Overgeneralizing or Vague Language

Avoid one-word summaries like “Client was upset.” Instead, be specific: “Client cried and stated, ‘I feel completely overwhelmed’.” Concrete details strengthen the note’s usefulness and defensibility.

2. Including Irrelevant Personal Details

Only document information pertinent to treatment. Extraneous personal stories or gossip compromise confidentiality and clutter the record. Stick to facts that inform diagnosis or plan.

3. Making Unsourced or Biased Statements

Never write assumptions as facts. Instead of writing “Client seems depressed,” use “Client reports feeling hopeless and tearful.” Assess all subjective reports (e.g., who said them) using objective facts and clinical criteria.

4. Repeating Rather Than Analyzing

Use the Assessment to interpret, not simply copy S and O. Instead of repeating what the client said, conclude: “Assessment: Anxiety appears exacerbated by work stress, per client’s report and increased muscle tension.” Avoid verbatim repeat.

5. Failing to Document Key Session Details

Include session length, therapy modalities used, and informed consent or safety planning when applicable. Omitting these can raise compliance issues. For example, note “60-minute individual session” or “treatment options and risks reviewed” as needed.

6. Delayed or Illegible Notes

Complete SOAP notes promptly to ensure accuracy. Handwritten notes must be legible, while digital notes should be reviewed for mistakes. Always sign and date your entries. Leaving portions blank or unsigned is a typical mistake.

By avoiding these errors and following the above-mentioned systematic procedure, you’ll be able to create high-quality SOAP notes that meet clinical, billing, and legal standards. Consistent, concise documentation facilitates tracking client progress over time and effective communication with colleagues, thereby increasing overall therapy outcomes.

Legal and Compliance Considerations

SOAP notes are part of the official treatment record. This has several implications:

• HIPAA and Privacy: Progress notes are part of the client’s chart and follow regular HIPAA rules. Avoid including overly sensitive personal reflections.
• Accuracy and Defensibility: Because SOAP notes may be reviewed by other physicians, auditors, or in court, they must be correct. Use proper documentation practices.
• Medical Necessity: In many health systems, SOAP notes justify billing. They must show that each service meets clinical criteria. That is why it is critical to document particular symptoms, obtain a diagnosis, and link actions to goals.
• Treatment Plan Integration: When creating SOAP notes, many EHRs encourage you to update or link to the treatment plan. Make sure your plan is up to date and in sync with each note.

Data Security: Store notes in secure, encrypted systems. Only discuss identifiable information in private settings and follow “minimum necessary” when sharing information among providers.

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Frequently Asked Questions

What does SOAP stand for in counselling?

Therapists utilize a standardized note format called SOAP (Subjective, Objective, Assessment, and Plan) to document sessions. It provides guidance for documenting the client’s reported difficulties, observable facts, clinical interpretation, and follow-up actions.

How do I start a SOAP note?

Begin by filling in the Subjective section with the client’s main complaints or symptoms. Then note any observations under Objective. This helps set up your Assessment and Plan sections based on those details.

Are SOAP notes the same as psychotherapy notes?

No. SOAP notes go in the client’s chart and are used for treatment documentation and billing. Psychotherapy notes are private therapist-only notes (more detailed and for reflection) kept separate under HIPAA protections.

Can I use bullet points in SOAP notes?

Yes. Bullet points for observations or lists are fine and often encouraged for clarity. Just ensure each bullet is a complete, understandable statement.

How long should a SOAP note be?

It varies. A concise SOAP note might be a few short paragraphs or 150–400 words, focusing on the key information. More complex cases can require longer notes. The goal is to be thorough but not overly wordy.

What tense should I write SOAP notes in?

Typically, progress notes are written in the past or present tense. For example: “Client reported feeling anxious. Client is tearful and fidgeting…” Stick to third person.

Should I include quotes from the client?

Yes, including exact client quotes in the Subjective section is often helpful. It provides an accurate record of what the client said and can be important for legal defensibility.

What if I make a mistake in a SOAP note?

Correct mistakes according to your organization’s policy. Often, a single line through the error with your initials and date, or using the EHR’s correction function. Never erase or obscure original text. Accuracy and transparency are key.

How do SOAP notes differ by therapy type?

The SOAP format stays the same, but the content differs. For example, a CBT session note might emphasize homework and thought records in the Plan, while a group therapy note might list participant behaviours under Objective. Always tailor the content to the context, but keep the SOAP structure.

Why are SOAP notes important in counselling?

SOAP notes create a clear, organized record of therapy. They help therapists track progress, make informed clinical decisions, communicate with other providers, and meet legal/insurance requirements. Good notes ultimately support better client care.