Clinical Template

SOAP Notes Template
for Clinicians

Last updated: March 2026

Reviewed by the WellNotes Clinical Team

Type or dictate brief session observations. Get a complete, insurance-ready SOAP note — structured, formatted, and ready to sign — in under 2 minutes.

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Used by Clinicians, BCBAs & Therapists

What are SOAP Notes?

SOAP notes are the most widely used clinical documentation format in healthcare and mental health settings. Originally developed by Lawrence Weed in the 1960s, the SOAP format provides a structured, logical framework for organizing clinical information after each patient encounter.

The acronym stands for Subjective, Objective, Assessment, and Plan — four sections that guide clinicians through documenting what the client reported, what was observed, the clinical interpretation, and the path forward. This structure ensures consistency across providers and supports continuity of care.

SOAP notes are required or preferred by most insurance companies, EHR systems, and regulatory bodies. Whether you work in private practice, a group practice, or an agency setting, mastering SOAP documentation is essential for compliance and clinical excellence.

How It Works

Three steps to a finished soap note

01

Describe the Session

Type a few sentences about what happened — or dictate with your voice. No special formatting needed.

02

WellNotes Structures Your Note

Your observations are organized into proper Subjective, Objective, Assessment, and Plan sections using clinical language.

03

Review, Edit, and Sign

Read through the note, make any edits, then export as PDF or copy to your EHR. Done.

SOAP Notes Sections Explained

Subjective

The client's self-reported experience — symptoms, feelings, concerns, and relevant history as described in their own words during the session.

Objective

Observable and measurable clinical data — the therapist's observations of the client's appearance, behavior, affect, speech patterns, and mental status.

Assessment

The clinician's professional interpretation — diagnosis updates, clinical impressions, progress toward treatment goals, and analysis of the subjective and objective data.

Plan

Next steps for treatment — homework assignments, session frequency, referrals, medication considerations, and goals for the next session.

Documentation Before & After WellNotes

Before WellNotes

Staring at a blank screen after your last session, trying to remember what the client said 3 sessions ago. 20 minutes pass. You still haven't started writing.

After WellNotes

Session ends. You type 3 sentences about what happened. A complete, structured SOAP note appears — ready to review and sign.

From 20+ minutes to under 2

SOAP Notes Example

A realistic sample generated by WellNotes

SOAP NotesExample

Subjective

Client reports increased anxiety related to upcoming work presentation. States "I keep imagining everything going wrong" and reports difficulty sleeping for the past 5 nights. Denies changes in appetite or substance use. Reports using deep breathing exercises from previous session with moderate success.

Objective

Client appeared well-groomed and oriented x4. Affect was anxious with intermittent hand wringing. Speech was normal in rate and volume. Thought process was linear but with evidence of catastrophizing. No suicidal or homicidal ideation. PHQ-9 score: 8 (mild depression, down from 12 last session).

Assessment

Generalized Anxiety Disorder (F41.1) — moderate severity. Client demonstrates insight into catastrophizing patterns and is actively engaging with CBT techniques. PHQ-9 improvement suggests positive trajectory. Anticipatory anxiety around performance situations remains primary treatment target.

Plan

1. Continue weekly CBT sessions. 2. Introduce cognitive restructuring worksheet targeting catastrophic thoughts. 3. Practice progressive muscle relaxation daily before bed. 4. Client to complete thought diary focusing on work-related anxious thoughts. 5. Reassess sleep quality next session. Next appointment: 1 week.

Who Uses SOAP Notes?

TherapistsPsychologistsCounselorsSocial WorkersPsychiatrists

Frequently Asked Questions

What is a SOAP note in therapy?+
A SOAP note is a structured clinical documentation format used by therapists, psychologists, and other healthcare providers. SOAP stands for Subjective (what the client reports), Objective (what the clinician observes), Assessment (clinical interpretation and diagnosis), and Plan (next steps for treatment). It is the most widely used progress note format in mental health and medical settings.
What is the difference between SOAP and DAP notes?+
The main difference is that SOAP notes separate client-reported information (Subjective) from clinician observations (Objective), while DAP notes combine both into a single Data section. SOAP notes are preferred when distinct subjective and objective documentation is needed — such as in medical or multidisciplinary settings. DAP notes are often favored by talk therapists who find the subjective/objective distinction less relevant.
How long should a SOAP note take to write?+
Most clinicians spend 15–30 minutes writing a SOAP note from scratch. With WellNotes, you can generate a complete, structured SOAP note in under 2 minutes by typing or dictating a brief summary of your session. You review and edit before signing — cutting documentation time by up to 90%.
Are SOAP notes required for insurance reimbursement?+
While specific requirements vary by payer, most insurance companies require structured progress notes that document medical necessity. SOAP notes are one of the most widely accepted formats and are preferred by many insurers, EHR systems, and auditors. Using a consistent SOAP format helps ensure your documentation meets reimbursement standards.
Can I use SOAP notes for group therapy sessions?+
Yes. Many clinicians use SOAP notes for group therapy by documenting each individual member's participation within the SOAP framework. WellNotes also offers a dedicated Group Therapy Notes template if you prefer a format designed specifically for group documentation.
Is my data secure?+
Yes. WellNotes is built with security and privacy at every layer. All data is encrypted in transit and at rest, session observations are processed server-side (never stored in the browser), and we do not train on your clinical data. WellNotes is designed for licensed clinicians who need documentation tools they can trust with protected health information.

Related Templates

DAP Notes

Data, Assessment, Plan — a streamlined format popular with counselors, social workers, and therapists in talk-therapy settings.

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BIRP Notes

Behavior, Intervention, Response, Plan — links clinical actions to outcomes. Used by counselors, behavioral health providers, and social workers in managed care settings.

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GIRP Notes

Goal, Intervention, Response, Plan — ties each session to treatment goals. Ideal for counselors, BCBAs, and rehabilitation professionals.

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Start Writing SOAP Notes in Minutes

Built for clinicians, by clinicians. Type brief session observations. Get a complete, secure soap notes — structured, formatted, and ready to save.

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