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How to wr�te SOAP notes (w�th
examples)
Publ�shed October 26� 2023
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Wonder�ng how to wr�te SOAP notes� The SOAP format can be one of the most
effect�ve wa�s for cl�n�c�ans to document and ob�ect�vel� assess� d�agnose� and
track plans for cl�ents�
�� The SOAP note format (Sub�ect�ve� Ob�ect�ve� Assessment� and Plan) �s a wa� for
cl�n�c�ans to document� assess� d�agnose� and track plans for cl�ents�
�� The Sub�ect�ve sect�on �ncludes what the cl�ent sa�s about the�r s�mptoms and
med�cal h�stor�� wh�le the Ob�ect�ve sect�on �ncludes the ph�s�cal f�nd�ngs from
the sess�on� such as v�tal s�gns and the cl�ent�s observed appearance�
�� The Assessment sect�on �s where the cl�n�c�an uses the �ns�ghts from the
Sub�ect�ve and Ob�ect�ve sect�ons to �nterpret the s�tuat�on and prov�de a
d�agnos�s� �f appl�cable�
�� The Plan sect�on outl�nes the treatment plan for the cl�ent� short- and long-term
goals� and expectat�ons for future sess�ons�
�� Best pract�ces �nclude prompt documentat�on� clear language� and adherence to
HIPAA gu�del�nes wh�le avo�d�ng sub�ect�ve op�n�ons and �rrelevant deta�ls�
Know�ng how to wr�te SOAP notes �s �ncred�bl� useful� helps
cl�n�c�ans capture the �nformat�on needed for clear� eff�c�ent� and effect�ve record
keep�ng�
In the SOAP format� SOAP stands for Sub�ect�ve� Ob�ect�ve� Assessment� and Plan�
Each letter refers to one of four sect�ons �n the document �ou w�ll create w�th �our
notes�
In th�s art�cle� we�ll cover how to wr�te SOAP notes� descr�b�ng the SOAP format and
what to �nclude �n each sect�on� We�ve also comp�led some SOAP note examples to
help �ou get started �n keep�ng sess�on notes and
�
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What�s a SOAP note�
Accord�ng to the �ournal Academ�c Med�c�ne� the SOAP format was developed �n the
1950s b� Lawrence Weed� a professor of med�c�ne and pharmacolog� at �ale
Un�vers�t��
Or�g�nall� referred to as a problem-or�ented med�cal record (POM�)�
� and toda� �t�s w�del� used b� pract�t�oners across man� healthcare
d�sc�pl�nes—�nclud�ng mental health profess�onals—to document and organ�ze
f�nd�ngs �n an ob�ect�ve wa��
Though the spec�f�c �nformat�on and length of these documents var�es b� d�sc�pl�ne�
�t�s �mportant to learn how to wr�te SOAP notes because the� all follow the same
bas�c structure� Th�s standard�zat�on �s eas�l� recogn�zable b� prov�ders �n other
spec�al�t�es—mak�ng �t eas� to �f needed�
How to wr�te a SOAP note
Learn�ng how to wr�te SOAP notes �s generall� a stra�ghtforward process because �t
alwa�s follows a spec�f�c and prec�se structure� However� �t does take some
pract�ce�
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• Sub�ect�ve
• Ob�ect�ve
• Assessment
• Plan
The notes and records �ou enter under each head�ng w�ll depend on �our cl�n�cal
spec�alt�� who �our cl�ent �s� and what �ou�re work�ng on dur�ng �our sess�ons
together�
We�ve broken down the order of how to wr�te SOAP notes and prov�ded suggest�ons
for what to �nclude �n each sect�on as recommended b� a rev�ew of peer-rev�ewed
art�cles �n �
Sub�ect�ve
Th�s sect�on �s for of how �our cl�ent sa�s the� are feel�ng
dur�ng the sess�on and what the� report about the�r current s�mptoms� It can also
conta�n �nformat�on gathered from fam�l� members and rev�ews of past med�cal
records�
Man� mental health pract�t�oners focus on what�s known as a �Ch�ef
Compla�nt�(CC) or the present�ng problem �n th�s sect�on�
Even �f the cl�ent reports mult�ple CCs� �t�s �mportant to tr� to �dent�f� the most
compell�ng problem so that �ou can ult�matel� prov�de an effect�ve d�agnos�s�
Some general areas of �nqu�r� as �ou tr� to �dent�f� the pr�mar� CC ma� �nclude�
h�stor� of present �llness� med�cal h�stor�� rev�ew of s�stems� and current
med�cat�ons�
�� Descr�be �our s�mptoms �n deta�l� When d�d the� start and how long have the�
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been go�ng on�
�� What �s the sever�t� of �our s�mptoms and what makes them better or worse�
�� What �s �our med�cal and mental health h�stor��
�� What other health-related �ssues are �ou exper�enc�ng�
�� What med�cat�ons are �ou tak�ng�
Make sure an� op�n�ons or observat�ons �ou �nclude �n the sect�on are attr�buted to
who sa�d them—whether �t�s �ourself or �our cl�ent� Because th�s �s a sub�ect�ve
sect�on� �ou don�t want to pass off an� of th�s �nformat�on as fact�
Ob�ect�ve
The SOAP notes should be made up of ph�s�cal f�nd�ngs gathered
from the sess�on w�th �our cl�ent�
• V�tal s�gns
• �elevant med�cal records or �nformat�on from from other spec�al�sts
• The cl�ent�s appearance� behav�or� and mood �n sess�on
Th�s sect�on should cons�st of factual �nformat�on that �ou observe and not
�nclude an�th�ng the pat�ent has told �ou�
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Assessment
The comb�nes all the �nformat�on gathered from the sub�ect�ve
and ob�ect�ve sect�ons� It�s where �ou descr�be what �ou th�nk �s go�ng on w�th the
pat�ent�
�ou can �nclude �our �mpress�ons and �our �nterpretat�on of all of the above
�nformat�on� and also draw from an� cl�n�cal profess�onal knowledge or DSM-5
cr�ter�a/therapeut�c models to arr�ve at a d�agnos�s (or l�st of poss�ble d�agnoses)�
Plan
The should outl�ne �our plan for next steps to treat
the pat�ent� �nclud�ng short- and long-term goals for �our pat�ent� Be spec�f�c about
what �ou plan to work on �n the next sess�on or �n general and �our expectat�ons for
the durat�on of treatment�
Therap� SOAP note example
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If �ou�re look�ng for an example for wr�t�ng SOAP notes� here�s a format
example that ma� help behav�oral health pract�t�oners better understand how to do
a SOAP note�
Cl�ent reports feel�ng more anx�ous th�s week� She sa�d she felt more ��tter� and on-
edge� and reports hav�ng more anx�ous thoughts that were harder to control�
Dur�ng the sess�on� the cl�ent was f�dget�� wr�ng�ng her hands� and speak�ng qu�ckl��
She appeared to have d�ff�cult� concentrat�ng and asked me to repeat quest�ons
mult�ple t�mes before respond�ng� Cl�ent descr�bed a fear of los�ng her �ob and her
hous�ng� though adm�tted she d�dn�t have an� ev�dence those events were
�mm�nent�
Based on the cl�ent�s reports and �n-sess�on observat�ons� the cl�ent�s anx�et� has
�ncreased but cont�nues to meet cr�ter�a for general�zed anx�et� d�sorder (GAD)�
�ecommended that cl�ent see a pr�mar� care ph�s�c�an to rule out an� th�ro�d or
other med�cal cond�t�on� Cl�ent w�ll cont�nue com�ng to therap� once a week for the
foreseeable future to treat anx�et� through cogn�t�ve behav�oral therap� (CBT)� Also
recommended that the cl�ent tr� med�tat�on and other m�ndfulness techn�ques at
home �n between sess�ons�
SOAP note example for speech-language
patholog�sts (SLPs)
(SLPs) also need to know how to wr�te SOAP notes�
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as SLPs use the SOAP format to capture cl�n�cal �nformat�on about cl�ent v�s�ts�
current assessments� and outcomes�
The cl�ent reports �ncreased vocal demands s�nce the last meet�ng due to add�t�onal
meet�ngs at work� She notes her colleagues commented ��our vo�ce �s back�� after
her last work presentat�on� but that she st�ll exper�ences �nterm�ttent vocal fat�gue
dur�ng soc�al events� She reports she has been �ncorporat�ng her sem� occluded
vocal tract straw (SOVT) rout�ne three t�mes a da� for f�ve m�nutes�
Led the cl�ent through SOVT exerc�ses w�th a straw �n water� Cl�ent �ndependentl�
ach�eved opt�mal vo�c�ng �n 5/5 opportun�t�es� Introduced conversat�onal tra�n�ng
therap� (CTT) where cl�ent d�fferent�ated between her �husk�� vo�ce and her
�presenter� vo�ce �n 5/5 opportun�t�es� Pract�ced funct�onal phrases where cl�ent
ach�eved �presenter� vo�ce �n 8/10 opportun�t�es w�th moderate v�sual cues� The
cl�ent�s vocal effort us�ng CTT was 4/10�
The cl�ent met goals of opt�mal vo�c�ng to meet vocat�onal demands� as ev�denced
b� an �mprovement from vocal effort of 7/10 (�somewhat hard�) to 4/10
(�somewhat eas��)� She �s press�ng toward carr�over of SOVT strateg�es to meet
soc�al demands�
Cont�nue the current plan of care� Target opt�mal vo�c�ng �n funct�onal env�ronments
w�th CTT techn�ques� Introduce add�t�onal compensator� strateg�es to manage
vocal load across vocat�onal and soc�al sett�ngs�
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How to use SOAP notes w�th �our pract�ce
management s�stem
�s the HIPAA-compl�ant pract�ce management software w�th eas�
and secure therap� notes� progress notes� SOAP notes� and other note-tak�ng
templates � Th�s makes �t fast and s�mple to access �our
notes and f�ll them out after each sess�on�
W�th bu�lt �n templates for SOAP notes �n the S�mplePract�ce software� �ou�ll never
f�nd �ourself search�ng for �nstruct�ons for how to wr�te SOAP notes ever aga�n�
S�mplePract�ce makes �t eas� for �ou to get more organ�zed and
�
If �our EH� doesn�t have bu�lt-�n SOAP notes� �ou can download our free SOAP note
template to keep on hand� or make �our own follow�ng the gu�del�nes we prov�ded
above�
�emember� SOAP notes are meant to document �our f�nd�ngs �n a wa� that�s eas� to
record and refer back to� Consequentl�� �ou should use the format that makes the
most sense for �our pract�ce�
If �ou�ve been cons�der�ng sw�tch�ng to a full� �ntegrated� HIPAA-compl�ant pract�ce
management software� g�ves �ou ever�th�ng �ou need to
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�ou can pull a SOAP note template from our robust template l�brar�� use our �load
prev�ous note� feature to eas�l� update �our notes each sess�on� and send follow-up
�nformat�on about �our sess�ons to �our cl�ents through the cl�ent portal�
Used b� over 225�000 cl�n�c�ans nat�onw�de� S�mplePract�ce �s cons�stentl� rated as
the ver� best pract�ce management software for therap�sts� speech-language
patholog�sts� occupat�onal therap�sts� and other pract�t�oners �n the health and
wellness �ndustr��
To tr� S�mplePract�ce out� � No cred�t card needed�
•
•
•
�� Academ�c Med�c�ne� (2019)�
�
�� StatPearls� (2023)� �
�� S�mplePract�ce� (2021)�
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�ou ma� also l�ke
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S�gn up for more
pr�vate pract�ce
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