What a SOAP note is
SOAP stands for Subjective, Objective, Assessment and Plan. The format came out of problem-oriented medical records in the late 1960s and is still the default progress note in most medical and many behavioral health settings.
Its defining feature is the split between what the client tells you (Subjective) and what you can observe or measure yourself (Objective). That split matters most when several providers read the same chart, because it lets a reader see which statements are self-report and which are clinical findings.
Assessment is where your clinical judgment lives: how the session data relates to the diagnosis and the treatment plan goals. Plan turns that judgment into concrete next steps. A reviewer should be able to read the Assessment and Plan alone and understand why the next session is needed.
When to use SOAP
- You work in or alongside a medical setting (primary care, psychiatry, hospital or integrated care) where colleagues expect SOAP.
- You give or record standardized measures (PHQ-9, GAD-7, vitals, rating scales) that belong cleanly in Objective.
- More than one provider documents on the same client and needs to tell self-report from observation at a glance.
- Your payer or agency asks for SOAP specifically. If they do not, DAP or BIRP may be faster for pure talk therapy.
SOAP field by field
What belongs in each section, and the one habit that most improves it.
Subjective
The client's own account: symptoms, stressors, mood in their words, response to last week's homework, and anything they report about sleep, appetite, substance use or safety.
Tip: Use a short direct quote when it captures severity better than a paraphrase, and attribute it ("Client stated...").
Objective
What you saw and measured: appearance, orientation, affect, speech, thought process, behavior in session, and any scores. Risk screening results go here as findings.
Tip: If a sentence starts with "client reports", it belongs in Subjective, not Objective.
Assessment
Your interpretation: how today's presentation relates to the diagnosis, whether the client is progressing toward treatment plan goals, and what is driving any change.
Tip: Tie at least one statement to a treatment plan goal. That is what makes medical necessity readable.
Plan
Next steps: interventions for next session, homework, referrals, coordination of care, session frequency, and anything you will reassess.
Tip: Write steps someone else could carry out if you were out sick next week.
Worked example
Fictional case: an adult client in outpatient therapy for generalized anxiety, session 6 of CBT. No identifying details.
Session details entered
- Client report
- Worried about a work presentation, sleeping about 5 hours, used breathing exercise 3 times, says it "took the edge off".
- Observations
- Restless, fidgeting, anxious affect, linear thought, GAD-7 = 13 (was 16 at intake). Denies SI.
- Interventions
- Cognitive restructuring on "I will freeze and get fired". Rehearsed opening lines.
- Plan
- Thought record before presentation, weekly sessions, recheck GAD-7 in 2 weeks.
Resulting note
Subjective:
Client reported increased worry about an upcoming work presentation and sleeping approximately five hours per night. Client used the paced breathing exercise three times this week and stated it "took the edge off."
Objective:
Client was restless with frequent fidgeting and presented with anxious affect. Thought process was linear and goal directed. GAD-7 score of 13, down from 16 at intake. Client denied suicidal ideation.
Assessment:
Symptoms remain in the moderate range with measurable improvement since intake. Anticipatory anxiety is maintained by catastrophic predictions about performance. Client engaged well in restructuring and generated a balanced alternative thought, consistent with progress toward the goal of reducing worry intensity.
Plan:
1. Client to complete a thought record before the presentation. 2. Continue weekly CBT sessions. 3. Readminister GAD-7 in two weeks. 4. Review sleep pattern next session.
Common SOAP mistakes
- Putting client self-report in Objective, which blurs the one distinction SOAP exists to make.
- An Assessment that restates the Subjective section instead of interpreting it.
- A Plan that says "continue treatment" with nothing a reviewer could check.
- Leaving out risk screening when it was done, or recording it without the result.
Frequently asked questions
Is this SOAP note generator really free?
Yes. You can generate one SOAP note per day without an account. The limit applies per device and per network, so it resets 24 hours after your last note.
Can I paste real client information?
No. This public tool is for de-identified information only. Leave out names, dates of birth, addresses, contact details and anything else that could identify a person. Describe the session in general clinical terms instead.
What goes in Subjective versus Objective?
Subjective is what the client tells you. Objective is what you observe or measure: appearance, affect, behavior, test scores. If you could not have known it without the client saying it, it is Subjective.
How long should a SOAP note be?
Long enough that another clinician or a reviewer can follow what happened and why the plan follows. For a routine outpatient session that is often 150 to 300 words. Clarity matters more than length.
Do insurance companies require SOAP notes?
Payers generally require notes that document medical necessity, not one specific acronym. SOAP is widely accepted, but DAP, BIRP and GIRP are too. Check your payer contracts and agency policy.
Is the generated note ready to sign?
Treat it as a draft. Read it, correct anything that does not match the session, and add what only you know before it goes in the record. You are responsible for the final note.