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

Writing clear and effective SOAP notes is essential for mental health counselors. SOAP stands for Subjective, Objective, Assessment, and Plan, guiding you to organize client information in a simple, structured way. We will walk you through a workflow for crafting SOAP notes that capture your client’s experiences, observations, clinical impressions, and detailed treatment strategies. 

Along the way, we share practical examples to illustrate each step, making it easy to apply these methods in your practice. Whether you’re starting or refining your skills, this guide simplifies documentation and boosts your confidence in keeping thorough, consistent, and clear professional records.

Understanding the SOAP Note Structure

The SOAP note format (Subjective, Objective, Assessment, Plan) is widely used in therapy to organize session information in a clear, standardized way. In the Subjective (S) section, record the client’s report of symptoms or feelings, often using their exact words. 

The Objective (O) section contains what the clinician observes or measures, such as the client’s appearance, behavior, affect, and test or scale results. 

The Assessment (A) is the clinician’s clinical interpretation or diagnosis, synthesizing the subjective and objective data into a summary of the client’s status. 

Finally, the Plan (P) outlines next steps: treatments provided in session, homework or coping strategies assigned, referrals, and follow-up plans. Using this structure ensures consistency and completeness in progress notes.

• Subjective (S): The client’s self-report of their current experience (feelings, thoughts, symptoms) since the last session. This often includes quotes or paraphrases of the client’s statements (e.g., “Client reports feeling anxious and unable to sleep,” etc.).
• Objective (O): Factual, observable information noted by the therapist. This can include the client’s mood and affect, behavior in session, speech patterns, mental status exam findings, and any objective measures (e.g., rating scales or vital signs). For example, “Client appeared restless, wringing hands; speech rapid; GAD-7 score = 16.”
• Assessment (A): The clinician’s analysis of what S and O indicate. This often includes the clinical diagnosis or formulation (e.g., “Generalized Anxiety Disorder”), symptom severity, and any changes since the last visit. It may also note barriers or progress toward goals.
• Plan (P): The treatment plan and next steps. Document the interventions used during the session, assignments or skills for the client to practice (e.g., coping strategies, homework), any referrals (medication review, community resources), and scheduling of the next session.

SOAP notes are just one common progress-note format (others include DAP, BIRP, etc.), but they are prized for their clarity and flexibility. Many behavioral health EHRs provide built-in SOAP templates with labeled fields to streamline this process. 

In all cases, remember that progress notes are part of the official medical record. They may be shared with other providers or auditors, so documentation must be clear, objective, and professional. (Psychotherapy “process” notes, by contrast, are kept separate and private when used.)

Step-by-Step SOAP Note Workflow

1. Prepare Before the Session

Review the client’s chart and treatment plan before the session. Note any upcoming issues (e.g., medication refills, previous goals). Open your EHR to a SOAP note template and ensure client identifiers (name, DOB, date/time) are correct. Briefly plan what you hope to cover. 

If there were any urgent messages or risk flags, gather those first. This pre-session step saves time and ensures you are focused on the client, not documentation, during the session.

2. Document During the Session

While listening to the client, jot key points in each SOAP section. For example, note direct quotes or symptom descriptions under Subjective, and mark observable details (affect, behavior) under Objective. 

Many clinicians use shorthand or bullet points on a notepad (or quick notes in the EHR) so as not to lose engagement. Don’t write everything verbatim in real time – just the salient facts. Keep the note up-to-date with prompts (some EHRs have checklists or voice-recognition input to capture things quickly).

3. Complete the Note Immediately After Session

As soon as possible (ideally right after the session), fill in and polish the note while details are fresh. Write the Assessment based on the client’s status (e.g., diagnosis, symptom changes) and any clinical impressions. Then record the Plan: interventions delivered (e.g., “taught breathing exercise”), client assignments (e.g., “will log daily moods”), referrals (e.g., psychiatrist consult), and scheduling. 

Ensure you update or link to the treatment plan if new goals or changes have occurred. Complete notes promptly – typically within 24–48 hours – to enhance accuracy and compliance.

4. Review for Accuracy and Compliance

Before finalizing, re-read the note for clarity and thoroughness. Make sure each SOAP section is present and labeled. Use precise, objective language and avoid jargon or acronyms others might not understand. 

Check that you used person-first, non-stigmatizing terms (e.g., “client with depression” rather than “depressed client”). Verify that no sensitive details meant for psychotherapy notes (if used) were in the progress note. Sign or authenticate the note according to your EHR procedures (date, time, and provider signature). Once complete, the SOAP note serves as a clear record of the session’s content and plan.

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

Best Practices for Documentation

1. Be Clear and Concise

Use straightforward, professional language. Write full sentences when possible, and avoid vague terms (e.g., instead of “seemed anxious,” describe “patient fidgeted and stated feeling nervous”). 

Include quantifiable data where relevant (such as test scores or vital signs). The note should be easily understood by any clinician who later reviews it. Remember that another provider, auditor, or even the client may read your notes, so aim for clarity.

2. Use Person-First, Nonjudgmental Language

Always describe the individual before the diagnosis or behavior (e.g., “person with schizophrenia” rather than “schizophrenic person”). Avoid stigmatizing words or labels. Notes should respect the client’s dignity and perspective. For example, write “client reports avoiding social events” instead of “client refuses socialization”.

3. Document Only Relevant Information

Include details directly related to treatment and progress. Omit gossip, irrelevant personal stories, or opinions not based on clinical observations. Personal data about family or third parties should be limited to what’s necessary for care. (Keep highly sensitive or personal reflections in separate psychotherapy notes if you use them.) This helps maintain confidentiality and focus.

4. Maintain Legality and Compliance

Progress notes are legal records. They should never contain any information you wouldn’t be comfortable reading in court or sharing with other providers. 

Adhere to HIPAA requirements: store notes securely, use encrypted EHR systems, and only access notes in private. Be sure to document informed consent and any safety planning (especially for high-risk issues) in the note. Always sign and date your entries; many systems also log who edited a note and when.

5. Consistency and Accuracy

Use your EHR’s SOAP templates and dropdowns to stay consistent. For instance, many EHRs auto-fill demographics or link to the treatment plan. Customize templates for mental health fields (e.g., checkboxes for “suicidal ideation denied,” or pull in PHQ-9 scores). 

If using voice dictation, proofread carefully for errors. Finally, correct any mistakes by following your organization’s protocol (usually a single strikethrough, initial, and date; never obliterate original text). Keeping notes clear and accurate protects you and benefits the client.

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

Sample SOAP Note Examples

Below are example SOAP notes for common scenarios. These templates demonstrate concise, professional documentation for different conditions:

Example 1: Generalized Anxiety Disorder

Subjective: Client reports feeling “very anxious” daily, with heart palpitations and racing thoughts. States, “I worry all night and barely sleep.” Denies suicidal thoughts; expresses concern about managing stress at work.

Objective: Client appeared restless, wringing hands throughout the session. Affect was anxious and tense; speech was rapid but coherent.  GAD-7 score = 16 (moderate anxiety). No evidence of psychosis or intoxication. 

Assessment: Generalized Anxiety Disorder (moderate, DSM-5 300.02). Symptoms have increased since the last visit, likely related to the upcoming work deadline. The client shows good insight but has difficulty implementing coping strategies independently. 

Plan: Taught diaphragmatic breathing and guided relaxation exercises; client practiced deep breathing in session with moderate success. Assigned daily relaxation logs and encouraged regular exercise. Suggested limiting caffeine and screen time before bed. No medication changes today.  Will follow up in one week to assess anxiety management; consider CBT for anxiety if symptoms persist.

Example 2: Major Depressive Disorder

Subjective: Client states feeling “down” most days for the past two weeks, low energy, and trouble sleeping. Reports 5/10 motivation and “no interest” in previously enjoyed activities. “I just want to stay in bed,” says the patient. Denies suicidal intent today, but admits “thoughts of being better off gone.”  

Objective: Appearance disheveled, poor eye contact. Psychomotor retardation noted (slow movements, long pauses). Affect flat; mood described as “hopeless.” PHQ-9 score = 18 (moderately severe depression). Speech slowed; concentration was poor on the serial 7s test.  

Assessment: Major Depressive Disorder, recurrent, current episode moderate. No acute safety concerns (has a plan but no intent). Depression appears to be related to recent job loss and social isolation. Insight and judgment intact. No change to comorbid diagnoses.  

Plan: Reviewed crisis resources and safety plan (coping 24/7 hotlines). Discussed the importance of medication follow-up – recommended meeting with psychiatrist for antidepressant evaluation. Provided CBT-based coping worksheet (activity scheduling). Encouraged patient to re-engage with one social activity this week. Schedule therapy twice weekly for support and monitoring. Next session in 3 days to monitor mood; provider to follow up on medication referral.  

Example 3: Post-Traumatic Stress Disorder (PTSD)

Subjective: Client reports frequent nightmares and flashbacks related to a past car accident. States, “I feel terrified when I hear a honk,” and “I can’t help but relive the crash every morning.” Reports sleep ~4 hours/night, with panic waking. Admits to increasing isolation out of fear. Endorses hypervigilance and irritability; denies current suicidal ideation. 

Objective: Client appeared on edge, frequently scanning the room. Affect anxious, tearful at times. Speech is coherent but quick. Denies hallucinations or substance use. Impact scale: PTSD Checklist (PCL-5) score = 55 (suggests severe symptoms). Insight fair; judgment intact. 

Assessment: Post-Traumatic Stress Disorder (ICD-10 F43.10). Trauma symptoms are severe and impairing (sleep disruption, avoidance behaviors). Progress noted: client engaged in an EMDR session and was able to discuss trauma details. No signs of psychosis or acute safety risk at this time. 

Plan: Continued EMDR protocol today (processing trauma memory), client responded with moderate distress but completed one set of eye movements. Assigned grounding technique homework (5-4-3-2-1 technique when triggered). Encouraged journaling of feelings and triggers. Consulted a psychiatric colleague about possible prazosin for nightmares. Follow-up in one week to continue EMDR and check coping. Crisis plan reviewed, and patient agrees to call if nightmares escalate.  

SOAP Notes and EHR Integration

Modern EHR systems can significantly streamline SOAP documentation.

• Built-in SOAP Templates: Use the EHR’s templated SOAP note with labeled fields (S, O, A, P). This ensures you never omit a section. Customize templates for mental health (e.g., include mental status prompts or risk factors).
• Auto-Population: Leverage auto-fill features. Demographics, session dates, and even prior diagnoses can pull into your note automatically. Link notes to treatment plan goals when possible (some EHRs pull forward the relevant goal for that session). If you use rating scales, document scores in the EHR, and let them populate here.
• Efficiency Tools: Use drop-down menus and checkboxes for common observations (e.g., “affect: congruent” or “sleep decreased”) to save typing. Many systems allow custom quick phrases (e.g. typing .anx1 expands to “Client reports increased anxiety today”). Voice dictation can also expedite note entry—proofread as you go to ensure accuracy.
• Compliance Prompts: Enable reminders for mandatory fields. Some EHRs flag unsigned notes or missing elements (e.g., treatment plan updates, risk assessments) before you close the chart. Take advantage of these checks to maintain high-quality, complete documentation.

By fully utilizing EHR features, clinicians save time and reduce errors. Consistent templates improve coordination of care, as all providers see information in the same organized format.

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 your assumptions as facts. For example, instead of “Client seems depressed,” document the client’s report or observations: “Client reports feeling hopeless and tearful.” Attribute all subjective reports (e.g., who said them) and base assessments on objective data and clinical criteria.

4. Repeating Rather Than Analyzing

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

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 (within 24–48 hours) to ensure accuracy. Handwritten notes must be legible; digital notes should be proofread for typos. Always sign and date your entries. Leaving sections blank or unsigned is a common error.

By avoiding these pitfalls and following the structured workflow above, you’ll produce high-quality SOAP notes that support excellent clinical care, billing, and legal standards. Consistent, clear documentation makes it easier to track client progress over time and communicate effectively with colleagues, improving overall treatment outcomes.

Vozo EHR for your Healthcare Practices

From managing and organizing patient health records digitally to reducing medical errors, it significantly empowers providers to improve healthcare quality. 

If you are searching for the best EHR system for your healthcare practice, Vozo EHR can be your go-to choice. Our comprehensive EHR solution lets you focus more on patient care while carrying all the burdens and simplifying them.

• Vozo Cloud EHR’s cost-effective cloud subscription benefits all levels of practice.
• Our feature-rich EHR helps you rectify mistakes efficiently and speed up the process.
• Vozo Specialty EHR resonates with specialty practice needs and requirements.
• Our expert technical team has got you covered 24/7 if any needs arise.
• Our EHR System continues to scale as your healthcare practice grows to improve the user experience.

The Vozo Customized EHR solution benefits your healthcare practice by:

• Streamlining the administrative process
• Improving workflow efficiency
• Reducing proneness to errors
• Managing all the patients’ records in one place
• Offers greater efficiency and cost savings across the board.

Our specialty-specific tools, such as scheduling, patient portals, lab integration, cloud hosting, and more, meet your healthcare practice’s specific needs and requirements.

“Embrace Vozo EHR to reduce your burdens and enhance patient care.”