SOAP Notes are used by mental health professionals to document their patients’ progress and their interactions during therapy sessions. The acronym, SOAP, stands for Subjective, Objective, Assessment, and Plan. The SOAP Note format ensures that relevant patient information is captured logically and consistently. Your note-taking ability probably wasn’t tested during your education in behavioral health. That’s why we’ve provided basic SOAP Note examples for mental health professionals below, with explanations of each section.
About SOAP Notes
There are several kinds of therapy notes, and SOAP Notes fall under the Progress Note category. A subset of clinical notes, these provide details about client progress, such as diagnosis & assessment, symptoms, treatment and progress toward treatment goals. They are included as part of your patient’s medical records and are meant to be shared with your patient’s other healthcare providers.
Progress notes, such as SOAP Notes, follow a standard format. Mental health software, like Vagaro’s, offers an intuitive SOAP Note feature that breaks this format down simply. There are actually three types of SOAP Notes you can add with Vagaro, which this support article explains how to use.
For simplicity’s sake, the following is a breakdown of a common SOAP Note, with the kind of information to include, and tone of voice to use, in each section.*:
1. (S) SUBJECTIVE
The subjective section of a SOAP Note should contain your patient’s subjective complaints and history, i.e., their self-reported symptoms, feelings, and experiences. This section covers things talked about in your session and may include direct quotes from your patient.
The goal of subjective information is to uncover your patient’s chief complaint (CC). There may be more than one CC present, and your patient may not report on the primary one straight away. Ask as many relevant questions as possible.
In this section, you should uncover:
- Your client’s description of their current emotional state
- Any physical symptoms your client may be experiencing
- Recent life events that may be affecting your client’s mental health
- Your client’s sleep patterns, appetite, energy level & any other relevant information
- Relevant medical history, such as a history of present illness (HPI) and medications your patient may be taking
Remember to include only relevant information. Use only quotes from your patient or important people in their lives connected to their mood, motivation and awareness level. Always make sure these quotes are set apart with quotation marks.
Example for Therapist
Patient, Alex M., reports feelings of helplessness and depression. Alex says, “I just can’t control my thoughts and haven’t been sleeping well.” He reports becoming irritable when in public, saying, “I don’t understand what’s setting me off.” We discussed his sleeping habits, activity level, recent life events and current stressors that may be impacting his mood and sleep.
In this example, the provider documents the client’s self-reported symptoms and provides some context around the client’s current life situation. This information will be helpful in the assessment and planning stages of the SOAP Note.
2. (O) OBJECTIVE
The objective section of a SOAP Note is where you’ll document any pertinent observable and measurable data concerning your patient. Physicians use this field to record vital signs, physical exam findings, or diagnostic test results. As a mental health professional, you may include such observations as your patient’s appearance, behavior, speech, mood, body posture and affect when discussing certain subjects during your session.
The most important phrase to remember here is objective observations. Avoid assumptions, personal opinions, negative language or general statements that aren’t supported by observable evidence.
Example for Therapist
Alex is cooperative, though he wore a downcast expression during the session and was prone to long pauses when answering questions. The provider had to repeat several questions, suggesting Alex’s condition is affecting his focus. He would wring his hands and deflect whenever the subject of his military service came up.
In this example, the provider documents their patient’s observable behavior and speech patterns, which can provide insight into the patient’s mental status.
- (A) ASSESSMENT
The assessment field of your SOAP Note is where the first two fields come together. Here, you’ll analyze the subjective and objective data to formulate a diagnosis or clinical impression.
The assessment section may include a summary of your patient’s symptoms, any relevant history, and your clinical impression related to factors such as mood, orientation, risk of harm and assessment of progress towards goals.
Example for Therapist
Based on Alex’s self-report and observations during the session, the provider feels he is experiencing symptoms consistent with anxiety and major depressive disorder, with signs of PTSD. Lack of sleep exacerbates negative mood spirals and racing thoughts. The provider’s impression is that, while not yet severe, these symptoms are causing distress and impairment in Alex’s daily life and will worsen without intervention.
In this example, the provider analyzes the subjective and objective data available to them to formulate a clinical impression of their patient’s mental health.
- (P) PLAN
In the plan section of your SOAP Note, you’ll outline the next steps in your patient’s treatment. This field should include any interventions or treatments that will be implemented, as well as any referrals or follow-up appointments that are necessary.
You may cover the anticipated frequency & duration of therapy, short & long-term goals and different exercises you’ve asked your client to do between sessions.
Example for Therapist
The provider will continue psychotherapy with Alex on Thursdays at 4 p.m. Alex agreed to attend a local veterans’ group therapy meeting to see if this helps, and report back at our next session. Mutually decided that, in the next week, Alex will contact someone, either a friend from before his time in the military, or someone with whom he served and is close to, to help feelings of isolation. Alex will begin a CrossFit training program, for enjoyment as well as an outlet for depression and negative thoughts. The provider will continue to build trust with Alex, and slowly broach his combat experiences, family history and other sources of stress. Alex was reluctant to begin taking medication. The provider will continue to monitor the severity of his symptoms and will discuss medication again if they worsen. In this example, the provider outlines realistic and measurable goals that they and their patient have agreed upon. Included are physical, social and medical attributes that will contribute to the patient’s therapeutic goals.
Final SOAP Note Checklist
There are certain important guidelines that you, as a mental health professional, must remember when writing SOAP Notes:
SOAP Notes should be concise, objective & relevant to your patient’s treatment plan. Ensure accuracy of dates, times, names & tenses. Avoid obscure abbreviations or colloquialisms. Always attribute patient statements with quotation marks and qualify subjective statements with evidence. Don’t erase or remove errors. Rather, use a strikethrough, identify that spot as an “error,” and correct it. Avoid moral judgements when representing your patient and use terminology that is accepted in the mental health field. Finally, write your SOAP Notes promptly after the session to ensure accuracy and completeness.
Video Telehealth SOAP Notes
Progress notes are also required of telehealth sessions. Below are things to include in your SOAP notes if you are conducting therapy via telehealth:
- Session begin & end time
- A statement indicating that the session was provided via telehealth
- Your location, i.e, home vs. office (ensure that your location reflects the office address that your insurance company has on file).
- Names of all session participants (in the case of families, couples, etc..)
- Date of the next session
- The interventions
- Mental status of patient
*Disclaimer: These examples are intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.
——–
Proper patient documentation shows your competency as a clinician and illustrates how your patient’s needs have been addressed. While keeping them may seem tedious to some, they are necessary toward delivering the best treatment possible.
Vagaro’s HIPAA-compliant practice management software streamlines mental health SOAP Notes and other patient documentation. All notes are automatically stored to a patient’s profile for easy future access. Going paperless with EMR patient notes & forms is just one way that Vagaro can help you run your private practice more efficiently and put patients first. Taking better care starts with Vagaro. Sign up for your FREE 30-day trial and see for yourself!
