SOAP Notes
A SOAP note is a structured method of clinical documentation that organises session information into four sections: Subjective, Objective, Assessment, and Plan.
What Are SOAP Notes?
SOAP notes are one of the most widely used formats for clinical documentation in therapy and healthcare. The acronym stands for:
- Subjective: The client’s self-reported experiences, feelings, and concerns
- Objective: Observable facts, therapist observations, and measurable data
- Assessment: The therapist’s clinical interpretation and analysis
- Plan: Next steps, treatment goals, and follow-up actions
When to Use SOAP Notes
SOAP notes work best for structured, goal-oriented therapy sessions. They are especially common in:
- Cognitive Behavioural Therapy (CBT)
- Insurance-reimbursed sessions requiring standardised documentation
- Multi-disciplinary team settings where notes are shared
How to Write a SOAP Note
Subjective
Record what the client reports in their own words. Include mood, presenting concerns, and any changes since the last session.
Objective
Document your clinical observations: affect, appearance, engagement level, and any assessment scores.
Assessment
Summarise your clinical judgement. Note progress toward goals, diagnostic impressions, and risk factors.
Plan
Outline the treatment plan going forward: homework, next session focus, referrals, and any medication considerations.
Common Mistakes
- Writing too much in the Subjective section and not enough in Assessment
- Confusing Objective observations with Subjective reports
- Leaving the Plan section vague instead of actionable
- Including unnecessary personal details that do not serve clinical purposes
Related Resources
Session Documentation
Session documentation is the process of recording clinical information from therapy sessions, including notes, assessments, and treatment updates.
Progress Notes
Progress notes are clinical records that document a client's treatment progress over time, including session summaries, interventions, and outcomes.
GIRP Notes
A GIRP note is a goal-oriented documentation format with four sections: Goals, Intervention, Response, and Plan — tying every session to treatment objectives.
BIRP Notes
A BIRP note documents therapy sessions in four sections: Behaviour, Intervention, Response, and Plan — focusing on what happened and how the client responded.
DAP Notes
A DAP note is a streamlined clinical documentation format with three sections: Data, Assessment, and Plan — combining subjective and objective information.
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