What are SOAP Notes in Mental Health and How Can They Be Used?

An Essential Tool for Documenting and Communicating Client Information

Sometimes, one might have nightmares for no reason at all. At other times, your work might be spilling over into your dreams! You are astonished. Aren’t you? Let me explain: you are a mental health provider struggling with hundreds of patient cases.

You scribble down unorganized therapy notes, and you end up crashing with therapeutic standards and regulations, not to mention the huge efforts you wasted trying to remember clients’ information while deciphering useless notes. No worries, we understand how much you are going through; it is for this reason that this blog exists.

In this blog, we tackle one of the most important tools that will arm you with the ability to convey clients’ information accurately, clearly, and succinctly, thereby serving as a key skill you should strive to master: we are talking about SOAP notes in mental health.

What Are SOAP Notes in Mental Health

Documenting clients’ information allows mental health providers to follow up with clinical encounters in a structured way. Generally speaking, clinicians use several means to organize their note-taking process with the intent of generating quick, clear, and effective therapy notes.

Typically, therapists choose the format they are most comfortable with as long as it ensures accurate documentation. This is mainly because there is no universally accepted therapy progress note format.

Nevertheless, three of the most popular formats are SOAP, DAP, and BIRP notes. As SOAP notes, the cornerstone of this article consists of four sections: subjective, objective, assessment, and plan; each to be further expanded.

You Might Be Pondering "What to Include in a SOAP Note.", well, here’s the answer.

SUBJECTIVE

Subjective data of SOAP notes, as the name implies, includes subjective statements reflecting the client’s condition. This section assists you, as a provider, in keeping track of important information reported by the client(s). These include, but are not limited to, the client's presentation of problems, statements elaborating on those problems, and any relevant history or notable event that the client brings up. Set the stage for this section by starting with direct documentation of the information as collected by the patient:

What brought the patient to you? His primary complaint, as stated by him.

A thorough report of the patient’s subjective history: the onset of his/her symptoms, reported physical and other concerns, palliating or provoking factors, the degree to which those symptoms are bothering your client (severity of the patient’s symptoms), history, etc.

OBJECTIVE

Unsurprisingly, the objective section of your SOAP notes shall comprise objective, observable, quantifiable, and verifiable information as inferred from the client’s encounter. These encompass:

1. An introduction tackling the client’s overall condition
2. Objective observations, for example: "the client cried on two occasions, reiterating his desire to give up on everything."
3. Physical exam findings along with a general impression of the patient, followed by the results of any relevant diagnostic information you have performed. For example, "the client’s current score on the Beck Depression Inventory as compared to scores recorded previously"

Get your SOAP progress notes done in 2 minutes from Audio Session Recordings with Mentalyc

ASSESSMENT

After you have completed the subjective and objective sections of your SOAP note, it is time to delve into the craft of your assessment. In essence, the assessment section of your SOAP note can be viewed as a written evaluation of the client’s current session as it relates to the overall scope of therapy. This is your evaluation as a therapist of the effects of therapy to date. In short, the assessment section of your SOAP note helps you keep track of the:

• Effects of the current session
• Overall, therapeutic progression
• The client’s level of satisfaction and the need for readjustments
• Client progress and setbacks
• Areas requiring more clinical work.
• Effectiveness of treatment modalities
• Re-evaluation of treatment plan objectives
• Changes are needed to keep therapy on target.
• The need for diagnostic revisions

Of course, it is not necessary to address each of those areas in every single SOAP note, but you are expected to include statements summarizing information in the data sections along with comments assessing:

1. The effectiveness of the session. E.g. “The session seemed helpful in eliciting the client’s feelings about…”
2. The overall effects of therapeutic interventions. E.g. “The client continues to show steady progress in meeting treatment plan objectives”
3. The client’s positive but also negative outcomes. E.g. “The client reports increased suicidal thoughts”
4. Areas requiring more effort. E.g. “New stressors in clients’ lives, behavioral and environmental changes”
5. A periodic assessment and revision of the effectiveness of treatment strategies. E.g. “Hypnotherapy has not proven to be effective to date”
6. Finally, changes that are needed to keep therapy on target along with diagnostic revisions.

PLAN

Your SOAP note is not complete unless you explicitly explain the focus of future sessions based on the client’s current functioning level.

Delving into future therapeutic plans ensures adequate follow-up on the client’s progress and need for readjustments. In brief, the plan section of your note encompasses:

1. Homework assignments, i.e. assigned tasks to be completed outside of the counseling session E.g. “Daily meditation”, “logging down feelings”, etc.
2. Upcoming interventions. i.e. new treatment modalities to be implemented.
3. Content of future sessions i.e. problem areas that you will dwell upon during the upcoming sessions.
4. Treatment plan revisions i.e. concerning whether objectives are being met or not.
5. Referrals i.e. any referrals or additional suggested services. E.g. referral for a medication evaluation.

Last but not least

You are not alone! We are here to transform the note-taking process into growth opportunities. With enough effort and time, you will become proficient in drafting vital psycho-therapeutical documentation. And keep in mind that, as with every skill you need to master in this life, practice makes perfect!

An App for Psychotherapists

Mentalyc is a note-taking tool that uses AI to write notes. With Mentalyc all your note-taking needs are fully automated and your notes are sure to be consistently accurate and well-written. Mentalyc helps you save time, reduce compliance risk, and allow you to focus fully on your client during sessions and not have to scribble notes during your sessions. Mentalyc now offers all kinds of notes. To learn more visit: www.mentalyc.com or Register for a free trial.

Below is an example of a SOAP note written by Mentalyc AI:

Feel free to reach out to us and give your feedback about this by using the chat function at the bottom right corner of your screen. We would appreciate your feedback.

Reviewed by: Brittainy Lindsey

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About the author

Salwa Zeineddine

Salwa Zeineddine is an expert in the mental health and medical field. She has extensive experience in the medical field, having worked as a medical researcher at the American University of Beirut. She is highly knowledgeable about therapist needs and insurance requirements. Salwa is passionate about helping people understand and manage their mental health, and she is committed to providing the best possible care for her patients. She is an advocate for mental health awareness and works to ensure that everyone has access to the resources they need.

Learn More About Salwa