A SOAP note is a standardized method of clinical documentation used by healthcare and therapy professionals to record a patient interaction in an organized, easily digestible format. The acronym stands for Subjective, Objective, Assessment, and Plan. This guide gives you ready-to-use SOAP note templates for mental health roles, complete examples for anxiety and depression, a printable cheat sheet, a step-by-step Assessment guide, and a free AI SOAP note generator.

Mental health professionals use SOAP notes to capture client-reported feelings, observable clinical data, diagnostic impressions, and next steps in a format insurers and licensing bodies accept. You can master them the long way, by writing each one manually after every session, or you can use a tool that drafts them for you from a recording or a short summary. Mentalyc’s AI Note Taker automatically organizes session content into Subjective, Objective, Assessment, and Plan sections in your clinical voice, and the connected AI Treatment Planner keeps your Plan section aligned with measurable goals across sessions.

What is a SOAP note?

A SOAP note is a standardized method of clinical documentation used by healthcare providers such as doctors, nurses, and therapists to track a patient’s progress and treatment. It is a structured clinical note with four sections: Subjective, Objective, Assessment, and Plan. The format ensures clear, consistent, and organized communication across the entire care team.

SOAP was developed by Dr. Lawrence Weed in the 1960s to give clinicians a consistent format for documenting patient encounters. Although it was originally a medical format, it has become widely used in mental health practice because the structure forces a clear separation between what the client reports, what the clinician observes, what the clinician concludes, and what comes next.

Mental health professionals use SOAP notes for anxiety, depression, trauma, substance use, intake, and ongoing therapy, because the format works for any clinical focus. Other formats you might encounter include DAP notes (Data, Assessment, Plan) and BIRP notes (Behavior, Intervention, Response, Plan). The choice often comes down to clinician preference and what payors or licensing boards in your jurisdiction require.

What does SOAP stand for?

SOAP stands for Subjective, Objective, Assessment, and Plan. The four letters map to the four sections of the note, and each section answers a different clinical question: what the client is telling you (S), what you are observing (O), what your clinical interpretation is (A), and what happens next (P).

What goes in a SOAP note?

A SOAP note contains four sections in fixed order:

• Subjective: what the patient or client tells you. Chief complaint, symptoms, history of present illness, and how long the issue has been going on. Include direct quotes where relevant.
• Objective: measurable, observable data. In mental health, appearance, behavior, affect, speech, and standardized assessment scores (GAD-7, PHQ-9, MSE).
• Assessment: the clinician’s professional evaluation and clinical reasoning. Diagnosis or differential, severity, progress, risk, and contributing factors.
• Plan: the next steps in treatment. Interventions, goals, medications, referrals, homework, and follow-up cadence.

Components, usage, purpose, and criticisms of SOAP notes

Components. A SOAP note has four components: Subjective (patient’s report), Objective (observable data), Assessment (clinical interpretation), and Plan (next steps). Each component answers a different clinical question and feeds into the next.

Usage. SOAP notes are used by therapists, psychologists, psychiatrists, counselors, clinical social workers, and psychiatric nurses to document mental health encounters. They are written after every session and shared across the care team to maintain continuity.

Purpose. The purpose of a SOAP note is to create a structured, defensible record of what happened in a clinical encounter. It supports treatment continuity, insurance reimbursement, audit readiness, supervision, and legal protection.

Criticisms. Common criticisms of SOAP notes include: they can be time-consuming, the format can flatten complex mental health presentations, the boundary between Subjective and Objective is sometimes blurred in therapy, and the structure can encourage formulaic writing over genuine clinical reasoning.

Why SOAP notes matter for mental health practitioners

SOAP notes matter because they give clinicians a single, standardized format that is fast to write, easy to share with other providers, and accepted by insurers. The format strengthens four parts of clinical practice at once.

Organized and systematic. SOAP notes follow a standardized format, ensuring that all relevant information is documented consistently. This allows you to review and understand a client’s progress over time easily.

Enhanced memory recall. With SOAP notes, there is no scrambling to remember the details of previous sessions. The subjective section captures the client’s thoughts, feelings, and perceptions, while the objective section records concrete observations.

Collaborative care. SOAP notes facilitate seamless collaboration among colleagues. By sharing SOAP notes, mental health practitioners can ensure continuity of care and provide insights to other professionals involved in the client’s treatment.

Evidence-based analysis. The assessment section of SOAP notes is a crucial tool for analyzing and interpreting the subjective and objective information clients provide. This evidence-based analysis establishes diagnoses, clinical impressions, and informed judgments. It guides treatment decisions and ensures interventions are based on sound clinical reasoning.

Goal-oriented planning. The plan section outlines the actions needed to address the client’s issues, comprising setting achievable goals, identifying interventions, making referrals, and determining next steps.

The four parts of a SOAP note

1. Subjective: capturing client-reported feelings

The Subjective (S) section of a SOAP note captures what the patient or their family tells you. This includes the chief complaint, current symptoms, their personal experience of the problem, and how long it has been going on. The Subjective section is based entirely on what the client or their caregiver reports, in their own words.

For mental health, the Subjective also captures details about history of present illness, medical and family history, and any relevant social or environmental factors. When writing this section, it is essential to use the client’s words as much as possible. Quote directly when a statement captures something the paraphrase would lose.

Example. Jane reports feeling “overwhelmed and anxious” about the job interview she has coming up. She states, “I am not able to sleep because my mind won’t shut up.”

2. Objective: documenting observable data

The Objective (O) section of a SOAP note contains factual, measurable, and observable data gathered by the clinician. It excludes opinions or interpretations, focusing solely on what can be independently seen, heard, measured, or tested. In mental health, the Objective section covers the client’s appearance, behavior, affect, speech, and any standardized assessment results from the session, such as a GAD-7 or PHQ-9 score.

What to include in the Objective section:

• Appearance: grooming, dress, posture, eye contact.
• Behavior: psychomotor activity, mannerisms, cooperativeness.
• Speech: rate, rhythm, volume, articulation.
• Affect: observed emotional expression and its range.
• Assessment scores: GAD-7, PHQ-9, MSE findings, any tools administered or reviewed.

Subjective vs Objective in SOAP notes. Subjective is what the client says. Objective is what you observe or measure. The distinction matters because clinical interpretation belongs in Assessment, not Objective.

Example. Jane appeared tired, with dark circles under her eyes. She fidgeted throughout the session and spoke quickly. She scored 15 on the GAD-7, indicating moderate anxiety.

For a deeper walkthrough on writing this section, see our dedicated guide on the Objective section of a SOAP note.

3. Assessment: therapist evaluation and diagnosis

The Assessment section of a SOAP note is where you synthesize the Subjective and Objective data into a clinical interpretation. This is the place for diagnosis or differential diagnosis, severity assessment, evaluation of contributing factors, and any risk concerns. In cases of anxiety or depression, the assessment focuses on the severity of symptoms, the effectiveness of current interventions, and any co-occurring conditions.

Quick example. Jane is describing symptoms consistent with Generalized Anxiety Disorder. She is concerned about an upcoming job interview. Current stress is affecting her sleep and everyday living. She is motivated to find strategies to cope.

What is the Assessment section of a SOAP note?

The Assessment section of a SOAP note is the clinician’s professional evaluation and clinical reasoning. It synthesizes the Subjective and Objective data to identify the client’s condition, track progress, and establish a diagnosis. The Assessment answers two questions every reader of the note needs answered: What does this mean? and Is the client improving?

For psychotherapists, the Assessment section goes beyond the integration of subjective and objective data. It involves interpreting the psychological, emotional, and sometimes physiological factors influencing a client’s mental health. It is the segment of the note where clinical skills and judgment are most evident, and it serves as the bridge to the Plan section.

Start every Assessment with a Clinical Summary opening statement

Open the Assessment with a concise one-sentence clinical summary that names the client’s age, presentation, primary diagnosis, and current status. This opening statement orients any colleague or auditor reading the note in 10 seconds, and it is the sentence Google’s AI Overview is most likely to extract from your note.

Pattern. “This is a [age]-year-old [gender] with a [duration] history of [primary issue], currently [status: improving/stable/worsening] on the current treatment plan.”

Example. “This is a 34-year-old female with a 6-month history of Generalized Anxiety Disorder, demonstrating moderate improvement in panic frequency over 4 weeks of CBT but persistent social avoidance.”

After the opening statement, expand into the elements below.

What goes in the Assessment part of a SOAP note?

A complete mental health Assessment contains six elements:

1. Diagnosis or Clinical Impression. The primary condition or conditions being treated, named using DSM-5-TR or ICD-10 terminology, plus any differential diagnoses being ruled in or out.

2. Clinical impressions and reasoning. The therapist’s professional judgment about the client’s psychological state and any changes in symptoms, and why you reached that conclusion.

3. Progress toward goals. The client’s progress toward their therapeutic goals, including improvements in specific behaviors, thought patterns, or emotional states, as well as any setbacks.

4. Therapeutic alliance. The quality of the therapeutic relationship. Note whether the alliance is strong and supportive or if there are ruptures needing repair.

5. Risk assessment. Any immediate risks to the client or others, such as suicidal ideation or self-harm behaviors.

6. Cultural and contextual factors. Cultural, social, or environmental factors affecting the client’s mental health.

How to write the Assessment section: a 10-step checklist

Use these steps to write a clear, defensible Assessment every time:

1. Integrate information. Combine the client’s subjective information (S) and the collected objective data (O) into a coherent assessment.

2. Use clinical judgment. Interpret the data using professional judgment, reflecting a clinical understanding of the client’s current status.

3. Diagnosis and differential diagnosis. Include a diagnosis based on the information gathered, and consider differential diagnoses.

4. Identify changes. Note any changes in the client’s condition since the last session.

5. Consider biopsychosocial factors. Incorporate biological, psychological, and social factors influencing the client’s condition.

6. Prioritize issues. If there are multiple concerns, prioritize them based on urgency, severity, or the client’s own concerns.

7. Use clear and concise language. Write professionally and avoid jargon that might be unclear to others reading the note.

8. Support with evidence. Where possible, support the assessment with reference standards of care, guidelines, or clinical protocols.

9. Reflect on treatment effectiveness. Assess whether to continue, adjust, or change the treatment plan.

10. Plan for the future. Use the assessment to inform the next steps in treatment.

When writing the Assessment, be comprehensive yet concise. Use language that respects the client’s experience and avoids pathologizing.

Holistic lenses to apply during assessment

A strong Assessment integrates multiple clinical perspectives rather than defaulting to a single framework:

• Psychodynamic insights. Consider defense mechanisms, unresolved conflicts, and family dynamics.
• Cognitive-behavioral patterns. Assess dysfunctional thought patterns, beliefs, and behaviors; identify cognitive distortions.
• Humanistic and existential factors. Reflect on the client’s sense of meaning, freedom, isolation, and authenticity.
• Cultural and social determinants. Evaluate cultural background, socioeconomic status, and social support systems.
• Differential diagnosis. Use diagnostic criteria from the DSM-5-TR or ICD-10, but also rely on clinical experience.
• Immediate risks vs. long-term issues. Prioritize immediate safety and risk issues before longer-term goals.

Example of Assessment in a SOAP note (full labeled format)

Here is a SOAP note example showing what a complete Assessment section looks like in practice:

Subjective: The client reports feeling “a bit more hopeful” this week, attributing this change to implementing coping strategies discussed in previous sessions. They mention ongoing struggles with anxiety, particularly in social situations, but note a decreased frequency of panic attacks.

Objective: The client appeared more engaged and open during the session than previously observed. They shared a detailed account of using deep breathing techniques to manage a panic attack at work. However, the client still shows signs of social withdrawal, opting out of a recent family gathering.

Assessment:

• Clinical Impressions. The client’s report of feeling “more hopeful” and the observed increase in engagement suggest a positive response to therapy. The successful application of coping strategies indicates improvement in self-regulation skills. However, the persistent avoidance of social situations highlights an ongoing area of need.
• Progress Toward Goals. The client has made commendable progress toward reducing panic attack frequency. Progress toward improving social engagement remains limited.
• Risk Assessment. There is no current evidence of suicidal ideation or self-harm.
• Cultural and Contextual Factors. The client’s social anxiety appears worsened by past experiences of bullying and a current remote work situation that reduces social interaction.

Assessment and Plan: how they connect

The Assessment section directly sets up the Plan section. Every conclusion in the Assessment should translate to a specific action in the Plan. If the Assessment identifies persistent social avoidance, the Plan should specify a graded exposure intervention. A SOAP note where the Plan does not follow logically from the Assessment is incomplete.

4. Plan: outlining next steps and treatment goals

The Plan (P) section of a SOAP note details the next steps in the patient’s treatment, including specific interventions, medications, referrals, homework, and follow-up cadence. Every item in the Plan should follow logically from the Assessment, and every goal should be measurable and time-bound.

What to include in the Plan section:

• Interventions to be used in upcoming sessions (modality, techniques).
• Medication changes or recommendations, if applicable.
• Homework or between-session tasks for the client.
• Referrals to other providers (psychiatry, PCP, group therapy).
• Frequency and timing of follow-up sessions.
• Safety planning if any risk was identified in the Assessment.

Example.

1. Continue weekly CBT focused on challenging anxious thoughts.

2. Practice progressive muscle relaxation 10 minutes daily.

3. Schedule a job-interview prep session before the appointment.

4. Re-evaluate sleep and anxiety in two weeks.

SOAP note cheat sheet

Download: the printable SOAP note cheat sheet (PDF) – a one-page S/O/A/P reference you can keep beside you during or right after a session.

Use this one-glance SOAP note cheat sheet during or right after a session. A printable mental health documentation cheat sheet is available at the end of this guide.

Do:

• Be concise but thorough.
• Use appropriate clinical language.
• Focus on pivotal information.
• Update treatment objectives regularly.
• Consider client strengths and progress.

Do not:

• Include subjective judgments in the Objective section.
• Use abbreviations that others may not understand.
• Include excessive irrelevant details.
• Forget to sign and date your note.
• Neglect to discuss safety risks.

Download the SOAP cheat sheet and 5 sample notes (PDF). The printable one-pager plus example SOAP notes for depression, anxiety, intake, substance use, and follow-up. (email-capture form to be added – on submit, route to a free Mentalyc trial.)

Prefer to skip the manual writing entirely? Mentalyc drafts the full SOAP note for you from a session recording or a short summary. Start a free trial and generate your first note in minutes.

SOAP note examples for mental health

Download: 5 example SOAP notes (PDF) – complete sample notes for depression, anxiety, intake, substance use, and follow-up, ready to adapt in your own documentation.

Two complete examples covering the most common presentations. For full printable single-page samples, see our SOAP note example for depressed mood and our SOAP note example for anxiety therapy.

Anxiety SOAP note example

Subjective

• Chief complaint: Patient reports feeling “constantly on edge” and experiencing panic attacks.
• History of present illness: Patient describes a 6-month history of increasing anxiety symptoms.
• Relevant personal and social history: Recent job loss, family history of anxiety disorders.

Objective

• Appearance: Anxious, fidgety, avoids eye contact.
• Behavior: Rapid speech, difficulty sitting still.
• Psychiatric symptoms: Reports excessive worry, restlessness, irritability, and sleep disturbances.

Assessment

• Diagnosis: Generalized Anxiety Disorder (GAD).
• Progress: Patient has been attending weekly therapy sessions for 2 months with some improvement in symptoms.

Plan

• Continue weekly therapy sessions focused on cognitive-behavioral techniques.
• Consider medication evaluation if symptoms do not continue to improve.
• Encourage patient to engage in relaxation exercises and regular physical activity.

Depression SOAP note example

Subjective

• Chief complaint: Patient reports feeling “hopeless” and lacking motivation.
• History of present illness: Patient describes a 3-month history of depressive symptoms.
• Relevant personal and social history: Recent relationship breakup, social isolation, family history of depression.

Objective

• Appearance: Disheveled, poor eye contact, flat affect.
• Behavior: Slow speech, minimal spontaneous movement.
• Psychiatric symptoms: Reports persistent sadness, loss of interest in activities, fatigue, and difficulty concentrating.

Assessment

• Diagnosis: Major Depressive Disorder (MDD).
• Progress: Patient has been attending bi-weekly therapy sessions for 1 month with minimal improvement in symptoms.

Plan

• Increase therapy sessions to weekly and incorporate cognitive-behavioral techniques.
• Schedule a medication evaluation with a psychiatrist.
• Encourage patient to engage in social activities and regular physical activity.

SOAP note templates by mental health role

The structure stays the same across every role, but the emphasis shifts depending on what you document for. Below are SOAP note examples for the mental health roles most commonly searching for them. For roles with their own dedicated guide, a deeper walkthrough is linked.

Psychotherapist, therapist, counselor: anxiety

S: The client reported feeling “stressed out” and “overwhelmed.” Stated, “I have been worrying constantly and can’t relax.” Reported trouble sleeping for the past week.

O: The client exhibited signs of anxiety, including rapid speech, leg shaking, and difficulty maintaining eye contact. Apologized frequently for “rambling.”

A: Anxiety. Insomnia related to excessive worrying and stress.

P: Discussed relaxation and mindfulness techniques for anxiety management. Recommended limiting screen time before bed. Will follow up in two weeks.

Therapist: work stress

S: The client reported experiencing high stress levels and feeling “crushed” over the past week. States trouble sleeping, concentrating, and increased anxiety.

O: The client presented as restless and fidgety. Speech rapid. Affect mildly anxious. Insight and judgment intact.

A: Anxiety related to increased work responsibilities and deadlines.

P: Discussed stress management and relaxation techniques such as controlled breathing, meditation, and limiting caffeine and screen time before bed. Recommended decreasing workload if possible. Follow up in two weeks.

Counselor in behavioral health: depression

S: The client states, “I have been struggling” with a depressed mood for the past month. Endorses feelings of hopelessness, low energy, and changes in sleep and appetite. No suicidal ideation.

O: Appearance disheveled. Psychomotor impairment is evident. Speech slowed. Affect depressed and tearful at times. Insight is good and judgment is intact.

A: Major Depressive Disorder, recurrent episodes, moderate.

P: Discussed therapeutic options of medications and therapy. Recommended psychiatry referral for medication evaluation. Referred to community support groups. Safety plan established. Follow up in one week.

Clinical psychologist: psychological assessment

S: The client, referred for diagnostic clarification, reports longstanding difficulty concentrating, “racing thoughts,” and mood swings that “have been there since college.” Requests testing to understand “what is actually going on.”

O: Administered the MMPI-2 and WAIS-IV. Client engaged and cooperative throughout the 90-minute battery. Validity scales within normal limits. Processing speed index notably below verbal comprehension.

A: Test findings, integrated with clinical interview, are consistent with a primary mood disorder with attentional features rather than a primary attention disorder. Differential remains open pending collateral history.

P: Complete remaining collateral interviews. Provide written assessment report within two weeks. Discuss findings and treatment options in feedback session. Refer to psychiatry for medication consult.

Psychiatric nurse (PMHNP): medication management

S: The client reports their mood has been “more even” since the last visit but continues to have early-morning waking and low energy. Denies suicidal ideation. Reports good adherence to current medication.

O: Mental status exam within normal limits. Affect brighter than prior visit. No psychomotor agitation or retardation. Vital signs stable. No evidence of medication side effects on exam.

A: Major depressive disorder, recurrent, moderate, partially responsive to current SSRI. Residual sleep disturbance and low energy.

P: Increase sertraline to 100 mg daily. Add sleep hygiene counseling. Continue weekly therapy with treating clinician. Follow up in four weeks to reassess symptoms, adherence, and side effects. For more on this format, see our guide on psychiatric nursing notes.

Clinical social worker (LCSW): depression and adjustment

S: The client reports feeling “stuck and sad” since a recent divorce three months ago. Describes low motivation, withdrawal from friends, and difficulty concentrating at work. States, “I don’t recognize myself anymore.” No suicidal ideation.

O: Client appeared tired with constricted affect. Speech normal in rate and rhythm. Engaged readily and was tearful when discussing the divorce. Oriented and insightful.

A: Adjustment disorder with depressed mood related to divorce, with features overlapping major depressive disorder. Therapeutic alliance is strong.

P: Continue weekly individual therapy using a strengths-based and CBT approach. Assign behavioral activation homework. Reassess for major depressive disorder in three weeks. Provide referral to a divorce support group. For more on this format, see our guide on social work notes.

Psychiatrist: bipolar disorder medication management

S: The client reported medication is stabilizing mood; however, continues to struggle with side effects of sedation and weight gain. Stated mood has been “okay,” but motivation and energy remain low.

O: Psych exam within normal limits. No suicidal or homicidal ideation. Weight gain of 10 lbs since last visit, possibly related to medication.

A: Bipolar I disorder, current episode depressed. Improved with medication but suboptimal response due to side effects.

P: Discussed options for switching or augmenting medications. Will start Wellbutrin 150 mg in the AM in addition to current meds. Follow up in four weeks.

Psychiatrist: depression with comorbid anxiety

S: The client reports feeling increasingly depressed and anxious over the past month, with trouble sleeping, poor concentration, and loss of interest in activities. Claims relationship issues and work stress are contributing factors.

O: The client appears disheveled and fatigued. Speech coherent but slowed. Mood dysphoric and affect constricted. No evidence of psychosis or suicidal ideation.

A: Major depressive disorder, recurrent, moderate. Generalized anxiety disorder.

P: Continue current medications (Lexapro 20 mg, Buspirone 15 mg) with follow-up in four weeks. Recommended weekly psychotherapy. Encouraged regular exercise and a routine sleep schedule.

Family therapist (LMFT): systemic conflict

S: The family reports escalating conflict between the mother and adolescent son over school and screen time. The son states he feels “controlled”; the mother reports feeling “ignored and disrespected.” Both want “less fighting.”

O: During the session, family members interrupted one another frequently. The father was largely silent. Affect was tense; one rupture occurred and was repaired in-session.

A: Family system showing rigid conflict patterns and weak parental coalition. Communication breakdowns maintain the presenting conflict. Engagement and motivation are good across members.

P: Continue weekly family sessions using structural family therapy techniques. Assign a between-session communication exercise. Hold one dyadic session with the parents. For a deeper walkthrough, see our guide on family therapy notes.

Group therapy: process group

S: Six members attended the weekly process group. Two members reported progress applying coping skills; one disclosed a recent relapse and expressed shame. The group responded with support.

O: Group cohesion was strong. The relapsing member was tearful but engaged. One member remained withdrawn and was gently drawn in by the facilitator. No safety concerns observed.

A: Group functioning at a working stage. The relapse disclosure deepened group trust. The withdrawn member may need an individual check-in.

P: Continue weekly process group. Facilitator to check in individually with the withdrawn member. Introduce a relapse-prevention exercise next session. For a deeper walkthrough and a group note template, see our guide on group therapy notes.

Need a specialized template for children or couples?

For pediatric SOAP notes, where developmental milestones, parent-reported behavior, and play-therapy observations matter more, see our dedicated guides on pediatric SOAP notes and play therapy notes. For relationship-focused work, see our guide on couples therapy notes.

Writing one of these by hand after every session adds up fast. Mentalyc generates a complete, role-specific SOAP note from your recording or summary so you can review in under a minute instead of writing from scratch. Try it free.

Common mistakes to avoid when writing SOAP notes

The most common SOAP note mistakes are being too vague, leaving out key details, paraphrasing instead of quoting the client, and skipping clinical reasoning in the Assessment.

Not being specific enough. Rather than writing “client discussed relationship issues,” specify which issues were discussed and how the client felt. For example, “Client expressed frustration over lack of communication with a partner. Stated feeling unheard and underappreciated.”

Leaving out important details. Your notes should capture the most important elements of each session, including mood and affect, discussion themes, interventions used, goals set, and plans for the next session.

Failing to record the client’s direct quotes. When possible, record the client’s exact words. They provide valuable context and insight into their thoughts, feelings, and behaviors.

Missing the “so what.” Your notes should analyze themes, assess progress, discuss interventions, and reflect your clinical reasoning.

How to write effective SOAP notes step by step

Writing SOAP notes involves breaking sessions into four standard categories: Subjective, Objective, Assessment, and Plan.

1. Focus on one client issue per note. Avoid cramming multiple concerns into a single note.

2. Capture the Subjective with the client’s own words. Ask open-ended questions about intensity, frequency, and duration. Example: “Client reports feeling increasingly depressed over the past week with trouble sleeping and difficulty concentrating. States sadness is 8 out of 10 in intensity, occurring daily.”

3. Objectively observe. Note factual observations of appearance, mood, affect, speech, and behavior. Example: “Client made little eye contact, slouched in their chair, and spoke softly. Appeared tired with flat affect.”

4. Assess the analysis. Analyze subjective and objective data, provide a diagnosis or differential, and evaluate risks. Example: “Symptoms appear consistent with major depressive disorder, recurrent. No apparent safety risks at this time.”

5. Plan the intervention. Explain the treatment plan, including goals, interventions, session frequency, and referrals.

6. Update the assessment and plan regularly as the client’s condition changes.

7. Be concise and specific. Avoid vague language or unnecessary details.

8. Use the client’s words to convey their subjective experience accurately.

9. Separate subjective and objective information clearly.

What are SMART goals in SOAP notes?

SMART goals are treatment goals that are Specific, Measurable, Achievable, Relevant, and Time-bound. They belong in the Plan section, where they replace vague intentions like “reduce anxiety” with concrete targets that can be tracked over time.

How long should a SOAP note be?

A SOAP note should be as concise as the clinical complexity allows. Most mental health SOAP notes land between 150 and 400 words. Longer does not mean better. Clinical specificity does. If you cannot justify a sentence with “this changes the assessment or the plan,” cut it.

Are SOAP notes written after every session?

Yes, SOAP notes are typically written after every session, while the details are fresh. Writing immediately after the session preserves accuracy and lets you track the client’s progress over time.

In some cases there are exceptions, such as when multiple sessions occur within a short period. In such situations it may be appropriate to summarize multiple sessions in a single SOAP note, highlighting the key information and progress made.

Pros and cons of SOAP notes

SOAP notes are widely used because they are standardized, easy to share, and comprehensive. They also have real limitations: they take time to write, quality varies between clinicians, and the format can flatten the complexity of mental health work.

Pros

1. Standardized format. Providers can quickly access pertinent information about a client’s condition and treatment plan.

2. Improved communication. SOAP notes facilitate clear communication between providers, ensuring continuity of care.

3. Comprehensive documentation. SOAP notes provide a thorough, organized record, essential for legal and insurance purposes.

Cons

1. Time-consuming. Writing detailed SOAP notes can be time-consuming for busy professionals.

2. Inconsistent quality. Quality can vary significantly between providers.

3. Limited focus. Some critics argue SOAP notes may not capture the complexities of mental health documentation.

SOAP notes vs DAP vs BIRP

SOAP, DAP, and BIRP are all structured therapy note formats. SOAP separates Subjective from Objective, DAP combines them into Data, and BIRP centers the note on the client’s behavior and response to interventions.

Write SOAP notes automatically with Mentalyc

You can write SOAP notes manually after every session, or you can use an AI scribe to draft them from a recording or short summary. Mentalyc generates SOAP notes automatically from session recordings, audio uploads, dictation, or typed summaries. Below is an example of a SOAP note written by the Mentalyc SOAP Note Generator.

Subjective: The client presented with ongoing work-related stress, feelings of being overworked and tired, and uncertainty about his career path. He expressed a desire for a career change but felt unsure which direction to pursue. He reported experiencing anxiety and impatience, attributing these feelings to work stress and physical exhaustion. He stated, “I feel like I have no life. It’s like a working machine.”

Objective: A clinical interview was conducted to explore the client’s work stress, career concerns, and emotional state. No risks or safety concerns were identified.

Assessment: The client actively engaged in therapy, indicating a positive therapeutic alliance. His work-related stress is significantly impacting his energy levels, patience, and overall quality of life. The client’s anxiety and impatience appear persistent with no significant change since the last session.

Plan: The client will take a personality test and reflect on the results. In the next session, results will be discussed and coping strategies for managing work stress and anxiety will be developed. Continued therapy will address work stress, career uncertainty, and emotional regulation.

Mentalyc is among the most trusted HIPAA-compliant note-taking tools, making it a secure option for protecting client confidentiality. To try it, register today for a free trial.

Frequently asked questions

The bottom line

SOAP notes give you a consistent, defensible way to document therapy sessions. The format takes minutes to learn, days to apply confidently, and months to use without thinking. Use templates while you build the habit, follow the four-section structure on every note, and lean on tools that handle the writing so you can stay present with the client.

References

• Podder V, Lew V, Ghassemzadeh S. “SOAP Notes.” StatPearls Publishing, NCBI Bookshelf, 2025. https://www.ncbi.nlm.nih.gov/books/NBK482263/
• Weed LL. “Medical records that guide and teach.” New England Journal of Medicine, 1968;278:593-600 and 652-657. https://pubmed.ncbi.nlm.nih.gov/5637758/
• American Psychological Association. “Record Keeping Guidelines.” 2007 (reaffirmed). https://www.apa.org/practice/guidelines/record-keeping
• U.S. Department of Health and Human Services. “HIPAA for Professionals.” https://www.hhs.gov/hipaa/for-professionals/index.html
• Cameron S, Turtle-Song I. “Learning to Write Case Notes Using the SOAP Format.” Journal of Counseling & Development, 2002;80(3):286-292. https://onlinelibrary.wiley.com/doi/10.1002/j.1556-6678.2002.tb00193.x
• Substance Abuse and Mental Health Services Administration (SAMHSA). “Clinical Documentation in Behavioral Health.” https://www.samhsa.gov/

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