Clinical Template

SOAP Note Template and Examples

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Type or dictate brief session observations. Get a complete SOAP note, structured and ready to review, in under 2 minutes.

What is a SOAP Note template?

A SOAP note template has four sections: Subjective (what the client reports), Objective (what you observe or measure), Assessment (your clinical interpretation and progress toward goals) and Plan (next steps). Fill each section with session-specific facts, keep self-report separate from observation, and tie the Assessment and Plan back to the treatment plan.

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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 accepted by most payers and supported by most EHR systems, though documentation requirements vary by payer and setting. Whether you work in private practice, a group practice, or an agency setting, mastering SOAP documentation is essential for compliance and clinical excellence.

SOAP Note Template Structure

Use these 4 headings, in this order, for every soap note. Each card explains what belongs in the section.

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.

SOAP Note Examples

5 filled examples for different sessions, written in the template above.

All examples are fictional and de-identified. They show structure and level of detail, not clinical advice for a real client.

SOAP Note Example 1: Anxiety (adult, CBT)

Adult client in weekly outpatient CBT for generalized anxiety, session 6.

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.

SOAP Note Example 2: Depression (telehealth)

Adult client seen by video for major depressive disorder, session 4 of behavioral activation.

Subjective
Client reports mood as "a 4 out of 10, a little better than last week." Completed 3 of 5 planned activities (two walks, one call with a sibling) and noticed mood lifted after the walks. Continues to wake around 4 a.m. most nights. Denies suicidal ideation. Reports taking prescribed sertraline daily with no side effects noted.
Objective
Seen via secure video from home; client confirmed location and privacy at start of session. Casually dressed, appropriately groomed. Affect constricted but brightened when discussing walks. Speech slow, normal volume. Thought process linear. PHQ-9: 14 (previous: 17). Denied SI/HI when asked directly.
Assessment
Major depressive disorder, single episode, moderate. PHQ-9 down 3 points and activity completion improved from 1 of 5 to 3 of 5, consistent with early response to behavioral activation. Early morning waking persists and remains a target. No acute risk indicators identified today.
Plan
Continue weekly 50-minute telehealth sessions. Increase activity schedule to 5 activities with one social activity. Introduce sleep hygiene and stimulus control handout. Client to log mood before and after each activity. Coordinate with prescriber with client consent if sleep does not improve in 2 weeks. Repeat PHQ-9 next session.

SOAP Note Example 3: Adolescent (school avoidance)

15-year-old client seen individually, with parent joining for the last 10 minutes.

Subjective
Client reports attending school 3 of 5 days this week, up from 1 of 5. States mornings are "the worst part" and describes stomachaches before leaving home. Parent reports fewer arguments at the door and that client used the morning checklist twice. Client denies self-harm or suicidal thoughts.
Objective
Client arrived on time with parent. Initially quiet with limited eye contact, more engaged by mid-session. Affect anxious, congruent with content. Rated anxiety about returning on Monday as 7/10, falling to 5/10 after the coping rehearsal. No signs of acute distress.
Assessment
Anxiety-related school avoidance with partial improvement in attendance. Somatic complaints appear tied to anticipatory anxiety. Parent is following the agreed morning routine, which is supporting progress. Continued graded exposure is clinically indicated.
Plan
Continue weekly sessions. Next exposure step: attend full school days Monday through Wednesday, using the coping card on arrival. Parent to praise attendance and avoid extended reassurance at drop-off. With parent consent, request release to coordinate with the school counselor. Review attendance log next session.

SOAP Note Example 4: PTSD (trauma-focused therapy)

Adult client in cognitive processing therapy (CPT) after a motor vehicle accident, session 5.

Subjective
Client completed the impact statement worksheet and reports avoiding the freeway "less than before." Nightmares down from 4 to 2 this week. Identified a stuck point: "If I had left five minutes later, it would not have happened." Denies SI/HI. Reports no alcohol use this week.
Objective
Client alert and oriented, appropriately dressed. Became tearful when reading the impact statement aloud, recovered with grounding. Speech normal. PCL-5: 41 (baseline: 52). Engaged throughout the Socratic questioning exercise.
Assessment
Posttraumatic stress disorder. PCL-5 has dropped 11 points from baseline, and nightmares and avoidance are decreasing. Self-blame stuck points remain the main treatment target. Client tolerated the emotional content of the session without dissociation.
Plan
Continue weekly CPT, moving to challenging questions worksheets for the self-blame stuck point. Client to complete one worksheet daily. Continue graded freeway driving, 10-minute trips twice this week. Repeat PCL-5 at session 7.

SOAP Note Example 5: Substance use (alcohol, outpatient)

Adult client in outpatient counseling for alcohol use, using motivational interviewing.

Subjective
Client reports drinking on 2 days this week (3 to 4 drinks each time), down from 5 days at intake. States the urge is strongest after work on Fridays. Says "I want to cut back, but I am not sure about stopping completely." Denies withdrawal symptoms. Denies SI/HI.
Objective
Client on time, alert, no odor of alcohol, speech clear. Affect euthymic. AUDIT-C: 6 (intake: 9). Engaged in the decisional balance exercise and completed it in session.
Assessment
Alcohol use disorder, moderate. Reduced drinking days and lower AUDIT-C indicate progress. Client is in the contemplation to preparation stage regarding abstinence. Friday evenings are the main high-risk situation. No current withdrawal risk reported.
Plan
Continue weekly sessions using MI. Client to plan an alternative Friday activity and track drinks daily. Provide information on mutual support groups; client will consider attending one meeting. Reassess goals and AUDIT-C in 2 weeks. Review medical follow-up if drinking increases or withdrawal symptoms appear.

SOAP note examples by profession

The examples above are written for mental health sessions. Other professions use the same four sections with discipline-specific content in Objective and Plan:

How to Write a SOAP Note

  1. Subjective. Summarize what the client told you: symptoms, changes since last session, homework completion and relevant stressors. Use short direct quotes only when they add clinical meaning.
  2. Objective. Record what you saw and measured: appearance, affect, speech, behavior, mental status and any scores (PHQ-9, GAD-7, PCL-5). Note telehealth location and consent checks if your setting requires them.
  3. Assessment. Interpret the data. Say how the client is progressing toward specific treatment plan goals, what changed, and why continued treatment is needed. Include risk status when you assessed it.
  4. Plan. List concrete next steps: frequency, interventions for next session, homework, referrals, coordination of care and when you will reassess measures.
  5. Check it before signing. Read the Assessment and Plan alone. A reviewer should understand why the next session is needed without reading the rest of the note.

Want a structured first draft to compare with your own? Try the free SOAP note generator with brief, de-identified session details.

Common SOAP Note Mistakes

  • Mixing interpretation into Subjective or Objective ("client was resistant") instead of describing the behavior you observed.
  • Writing an Assessment that only repeats the Subjective section rather than interpreting it.
  • Leaving out risk screening when it was done, or documenting it without the client's actual response.
  • Copying the same Plan every week, which makes notes look cloned and hides real progress.
  • Including detailed process material that belongs in separate psychotherapy notes, if you keep them.

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.

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

Who Uses SOAP Notes?

TherapistsPsychologistsCounselorsSocial WorkersPsychiatrists

SOAP Note FAQ

What is an example of a SOAP note?

A typical SOAP note might read: Subjective, client reports sleeping 5 hours a night and worrying about work; Objective, anxious affect, GAD-7 of 12; Assessment, generalized anxiety with partial response to CBT; Plan, continue weekly sessions and practice a worry-postponement exercise daily. This page shows five full examples for different presentations.

How do you write a SOAP note for therapy?

Write the Subjective section from what the client reports, the Objective section from what you observe and measure, the Assessment from your clinical interpretation and progress toward goals, and the Plan from concrete next steps. Keep each statement specific to this session and link the Assessment and Plan to the treatment plan.

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.

Are SOAP notes required for insurance reimbursement?

While specific requirements vary by payer, payers generally expect progress notes that document medical necessity. SOAP is one of the most widely used formats, and a consistent structure makes it easier for reviewers to find what they need. Using a consistent SOAP format helps, but it does not by itself guarantee reimbursement.

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.

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