How to Write a SOAP Note in Therapy: Format, Examples, and Common Mistakes
By Kristen McClure, MSW, LCSW | TherapistWorksheet.com
SOAP notes are the most widely used documentation format in therapy — and the most commonly misused. Therapists who learn the format in grad school often develop habits that create liability rather than reducing it. This guide gives you a clear, practical framework for writing SOAP notes that hold up clinically and legally.
What Is a SOAP Note?
SOAP is an acronym for four sections of a progress note: Subjective, Objective, Assessment, and Plan. Originally developed in medicine, the format works well in therapy because it separates what the client reports from what you directly observe — a critical distinction in clinical documentation.
SOAP Note Format for Therapy: Section by Section
S — Subjective
What the client reported about their experience, mood, week, and symptoms. Always use attribution language: “Client reports,” “Client states,” “Client describes.” Never present a client’s account as established fact.
Example: “Client reports increased anxiety this week following a conflict with her supervisor. She describes difficulty initiating sleep and intrusive thoughts about work. She rates her mood as 4/10.”
O — Objective
What you directly observed during the session. Include appearance, behavior, affect, speech, and engagement. Do not put client reports here — only what you saw and heard yourself.
Example: “Client presented as casually dressed, well-groomed. Affect was anxious and mildly constricted. Speech was organized and goal-directed. Client maintained appropriate eye contact and was engaged throughout.”
A — Assessment
Your clinical impression of this specific session — not just a restated diagnosis. Include your clinical reasoning, relevant patterns, progress or regression, and your safety assessment.
Example: “Client presents with symptoms consistent with GAD. This session revealed a pattern of catastrophic thinking about professional competence. Safety assessment: denies current SI/HI. Appropriate for outpatient level of care.”
P — Plan
What happened and what happens next. Name the specific interventions you used (not just the modality) and your plan for the next session.
Example: “Used Socratic questioning to identify and challenge catastrophizing cognitions around work performance. Client completed a cost-benefit analysis of worry in session. Homework: thought record before next session. Next appointment: [date].”
Common SOAP Note Mistakes in Therapy
- Putting client reports in the Objective section — client-reported history is Subjective, not Objective
- Generic Assessment language — “Client presents with depression” is not an assessment of this session
- Missing safety documentation — every note should document your safety assessment, even when negative
- Vague interventions — “Used CBT” is not sufficient; name what you actually did
- Presenting third-party accounts as facts — “Client’s husband is abusive” vs. “Client reports experiencing her husband’s behavior as abusive”
SOAP vs. DAP: Which Should You Use?
DAP (Data, Assessment, Plan) combines the Subjective and Objective into a single Data section, making it faster to write. Use DAP for straightforward sessions; SOAP when clinical complexity warrants a clearer separation of what you observed from what was reported. Either format works for most payers — check your contracts.
SOAP Note Template for Therapy
S: Client reports [mood/symptoms/week in review]. States [specific quote or summary]. Rates mood [x/10].
O: Client presented as [appearance]. Affect was [quality]. Speech [quality]. Thought process [quality]. Engagement [quality].
A: Client continues to present with [diagnosis/pattern]. This session [specific clinical observation]. Safety: [SI/HI assessment]. Level of care: [appropriate/consider higher level].
P: [Specific interventions used]. Client response: [engaged/resistant/moderate insight]. Homework: [if applicable]. Next session: [date/focus].
Frequently Asked Questions
How long should a SOAP note be for therapy?
A complete SOAP note for a standard 50-minute session should be 150–300 words. If you’re consistently writing more than that, your template is doing too little work.
Do I need to use SOAP format if my EHR uses something different?
Follow your EHR’s structure — but the underlying principles apply regardless of format. Separating observed from reported, documenting safety, and naming specific interventions are universal standards.
Can I copy sections from note to note?
The structure and boilerplate can repeat. The clinical content must be specific to this client, this session. Copy-paste notes are flagged in audits and represent a real liability risk.
What goes in Objective if the session was uneventful?
“Uneventful” is still clinical data. A client who presents as calm, organized, and engaged is meaningfully different from last week when they were tearful and avoidant. Document the baseline.
Where does homework go in a SOAP note?
In the Plan section — both homework assigned and client’s completion of prior homework (which could appear in Subjective if the client reported on it).
Kristen McClure, MSW, LCSW is a licensed therapist who creates practical clinical tools to help therapists navigate the hardest moments in their work.