Documentation

How to write a SOAP note (with examples)

Subjective, Objective, Assessment, Plan — the audit-ready progress note in under 10 minutes.

6 min read·4 steps· Updated June 10, 2026

Paste what happened in the session — presenting concerns, themes, interventions delivered, client response, risk, plan. AI drafts a clinician-grade progress note in the format you choose (SOAP, DAP, BIRP, Narrative) and tone (concise, detailed, insurance-justification). Fully editable, copy-ready, sign-off-ready. No PII beyond initials.

SOAP is the most widely used progress-note format in behavioral health. It keeps your record audit-defensible, supervisor-readable, and useful to your future self at the next session. Here's exactly what to put in each of the four sections, with mental-health-specific examples.

Quick answer

A SOAP note is a four-part progress note with Subjective (client report), Objective (observation), Assessment (clinical interpretation), and Plan (next steps). For therapy, most SOAPs run 180–350 words and should explicitly address risk, name interventions by modality, and end with a concrete plan beyond 'continue therapy'.

Key takeaways

Subjective: Client's reported experience in their own words — mood, symptoms, stressors, sleep, appetite, suicidal ideation if relevant.
Objective: What you observed: affect, mental status, engagement, behavior in session, any measures administered (e.g.
Assessment: Your clinical interpretation: progress toward goals, current diagnostic picture, risk level, response to interventions.
Plan: Focus for next session, between-session homework, referrals, frequency, medication coordination, and any safety-planning steps.

When to use this

Outpatient therapy sessions billed to commercial insurance or Medicaid/Medicare.
Settings that audit for medical necessity and require separation of report from observation.
Trainees or supervisees whose notes will be reviewed link-by-link.

Steps

1
Subjective
Client's reported experience in their own words — mood, symptoms, stressors, sleep, appetite, suicidal ideation if relevant. Use brief quotes when they're clinically meaningful.
2
Objective
What you observed: affect, mental status, engagement, behavior in session, any measures administered (e.g. PHQ-9 = 14). Stick to observables.
3
Assessment
Your clinical interpretation: progress toward goals, current diagnostic picture, risk level, response to interventions. This is where you connect the dots.
4
Plan
Focus for next session, between-session homework, referrals, frequency, medication coordination, and any safety-planning steps.

Example

Sample SOAP note (session 6, CBT for GAD)

S: Client reports anxiety 'a little better,' rates 6/10 vs 8/10 last week. Sleep onset improved (~30 min vs 90 min). Denied SI/HI. 'The worry log is helping me catch it sooner.'

O: Punctual, casually groomed, fully engaged. Affect mildly anxious, congruent. Speech normal rate/volume. No psychomotor agitation. Completed PHQ-9 = 9 (down from 14), GAD-7 = 11 (down from 16).

A: Session 6 of CBT-GAD. Worry exposure homework completed 5/7 days; client able to identify 'intolerance of uncertainty' as a core driver. Symptom trajectory improving; functional engagement (returned to weekly gym) supports treatment response. Risk: low; no SI/HI; protective factors intact.

P: Continue weekly. Next session: scheduled-worry technique + behavioral experiment on uncertainty. Homework: 10-min worry window daily + one uncertainty exposure (RSVP to event without rehearsal). Re-administer GAD-7 in 4 weeks.

Quick checklist

PII reduced to chart minimum (initials, DOB on header, nothing in body).
Risk addressed in every note, even if 'denied SI/HI'.
Interventions named by modality and technique.
Plan is concrete: who/what/when, not 'continue therapy'.
Outcome measure scored and trended at least monthly.

Common variations

SOAP-IE

Adds 'Interventions' and 'Evaluation' as discrete sections — common in case management.

Group SOAP

Subjective and Objective focus on the individual client's behavior within the group; Plan references the group curriculum.

Evidence base

SOAP originated with Lawrence Weed's Problem-Oriented Medical Record (1968). It is accepted by all major US payers and is the default format taught in most accredited MSW and clinical psychology programs.

Deep dive

What insurance auditors actually look for in a SOAP note

Medicaid, Medicare, and commercial-payer auditors are scanning for medical necessity — proof that what you did in the room is treatment for a covered diagnosis and is producing change. Three sentences usually decide a note's audit fate: (1) a symptom-anchored statement in Subjective or Objective (a rating, a frequency, a behavioral observation, not 'client felt sad'); (2) a named, evidence-based intervention in Assessment ('Socratic questioning of catastrophic AT,' not 'we talked it through'); and (3) a measurable Plan that ties to the treatment plan goal ('rehearse cognitive defusion 1×/day; re-administer GAD-7 at session 10'). If a stranger reading the note cannot tell which diagnosis you are treating and which technique you used, the note will not survive review.

SOAP vs DAP vs BIRP vs GIRP — choosing the right format

SOAP is the broadest and most defensible format for outpatient therapy because it separates report from observation, which matters in custody, disability, and forensic contexts. DAP collapses S and O when the distinction is redundant — common in school and EAP settings. BIRP (Behavior, Intervention, Response, Plan) is preferred in community mental health and substance-use programs because Response demonstrates within-session change. GIRP front-loads Goal and is favored in case management and IOP. If your agency does not mandate a format, default to SOAP for individual therapy, BIRP for substance-use and group work, and DAP for brief or coaching encounters.

Common SOAP-note phrases that fail medical necessity

Strip these from your templates: 'continue with current plan,' 'supportive therapy provided,' 'processed feelings,' 'will follow up,' 'client was engaged.' None of them name a diagnosis, intervention, or measurable outcome. Replace with: 'Continued session 6 of CBT-I; reviewed sleep restriction adherence (5/7 nights),' 'Used Socratic questioning to test the prediction that …,' 'Identified parts polarization between protector and exile (IFS),' 'Re-administer PHQ-9 at session 8; refer to PCP for thyroid panel if mood does not improve by week 4.' Specificity is what makes the note both billable and clinically useful at session 12.

Tips

Use behaviorally specific verbs — 'practiced cognitive defusion' beats 'we did some ACT'.
Note interventions delivered by name (e.g. 'Socratic questioning of catastrophic AT').
Surface risk explicitly even when it's negative ('denied SI/HI; no plan or intent').