How to Write SOAP Notes: Examples & Template

What is a SOAP Note?

SOAP notes are a widely used method of documentation in healthcare, valued for their simplicity, structured format, and adaptability. They organize client or patient information into four key categories: Subjective, Objective, Assessment, and Plan, ensuring comprehensive and accurate record‑keeping. Here’s a closer look at each component:

Subjective (S):

Details the client’s condition and history, including major or minor complaints and whether the issue is recent or long‑term.

Objective (O):

Captures measurable and observable data gathered during the clinical encounter, both quantitatively and qualitatively.

Assessment (A):

Provides the therapist’s evaluation of the client’s condition, along with an interpretation of findings.

Plan (P):

Outlines the recommended treatment, follow‑up care, and any actions required for future correspondence.

Developed in the mid‑1960s by Dr. Lawrence Weed as part of the problem‑oriented medical record system, SOAP notes have since become an indispensable documentation approach across various fields, including medicine, nursing, physical therapy, and mental health.

How to Write SOAP Notes

SOAP notes adhere to a structured format designed to comprehensively document all aspects of a client’s visit to a therapist. Here’s a detailed guide to organizing your SOAP notes, ensuring clarity and thoroughly addressing the client’s history and current status.

Draft and Organize Your SOAP Notes

Simply start by organizing your notes into the four SOAP sections:

• Subjective: Record the client’s verbal description of their symptoms, concerns, and history. Include quotes where relevant to capture their perspective accurately.
• Objective: Document measurable and observable data, such as physical exam findings, vital signs, and test results.
• Assessment: Analyze the subjective and objective data to reach a potential diagnosis or record and update the client’s progress.
• Plan: Outline the next steps, including treatment options, follow-up appointments, or diagnostic tests.

Review and Interpret Your SOAP Notes

• Once you have completed drafting, review your notes for accuracy.
• Cross-check client's information for consistency between sections.
• Verify that the ‘Plan’ section is actionable and detailed and addresses all critical issues raised during the visit.
• Regularly reviewing SOAP notes will improve their quality and ensure they provide a complete clinical picture.

Enhance Your SOAP Notes with AI

• AI can convert client conversations into draft SOAP notes, saving time.
• It can highlight any inconsistencies or missing information for a more thorough review.
• AI can analyze patterns in client data, helping you refine your assessments and plans.
• By incorporating AI, you can reduce manual effort while maintaining high documentation standards.

Simplify and Standardize with Templates

• Templates provide ready to use sections for Subjective, Objective, Assessment, and Plan.
• Templates should be developed with certain practices or specialties in mind.
• Using templates ensures that providers consistently follow established protocols tailored to particular contexts.
• Templates make taking notes easier and help avoid missing important information.

SOAP Note Example for Mental Health Counseling

SOAP analysis is a valuable tool for counseling sessions, providing a structured framework to document key information clearly and comprehensively. Below is an example demonstrating how each section can be applied in a mental health counseling session:

S: Subjective

This section captures the client’s verbalized thoughts, feelings, and perceptions about their current state. It focuses on what the client shares during the session.

Example: The client stated, “I’ve been feeling overwhelmed and anxious lately. I can’t concentrate at work, and I keep worrying about things going wrong.” The client also reported having trouble sleeping, along with frequent headaches.

O: Objective

This section records the counselor’s factual observations during the session, including physical appearance, behavior, and non‑verbal cues.

Example: The client appeared restless, frequently fidgeting with their hands. Their voice was subdued, and they avoided eye contact throughout the session. No physical impairments or abnormalities were observed.

A: Assessment

In this section, the counselor evaluates the client’s mental health condition, progress, and engagement with therapy. It may include a diagnosis or a summary of the session.

Example: The client is exhibiting symptoms of Generalized Anxiety Disorder (GAD), such as excessive worry, difficulty concentrating, and physical symptoms like headaches and disrupted sleep. The client appears motivated to work on these issues and is open to therapeutic interventions.

P: Plan

This section outlines the next steps for treatment, including interventions, goals, and any changes in the therapeutic approach.

Example: The client will practice a 10-minute mindfulness meditation exercise daily to help manage anxiety. The therapist will introduce Cognitive Behavioral Therapy (CBT) techniques in the next session to address thought distortions. Follow-up is scheduled for next Tuesday.

SOAP Note Template

Benefits of Using SOAP Notes

SOAP notes offer mental healthcare professionals several advantages, including:

1. Tracking Progress and Identifying Patterns: By systematically documenting each session, SOAP notes help therapists monitor a client’s progress or setbacks over time. This continuity supports the development of effective strategies and therapeutic approaches tailored to the client’s needs.
2. Facilitating Information Sharing: SOAP notes standardize documentation, making it easier to share critical client information with other healthcare providers. This is especially valuable when coordinating care across multiple specializations or disciplines.
3. Improved Client Care: The structured format of SOAP notes enables therapists to focus on personalized treatment plans. The progressive nature of the notes ensures that each session builds on previous ones, contributing to a more efficient and cohesive treatment process.

Common Challenges in Writing SOAP Notes

Writing an effective and completely up‑to‑date SOAP note can be challenging. This problem is particularly common in people new to the process or working in fast‑paced clinical environments.

Best Practices for Writing Effective SOAP Notes

Crafting accurate and comprehensive SOAP notes can be difficult, especially for those new to the process or operating in high‑pressure clinical settings. Adhering to some best practices can significantly help with these challenges, ensuring clarity, consistency, and efficiency in documentation:

1. Maintaining Consistency

Consistency is key to making SOAP notes easy to follow and reliable. Follow the SOAP format ‑ Subjective, Objective, Assessment, and Plan ‑ strictly to ensure that each note is legible and that all the puzzle pieces fit where they are supposed to. Moreover, SOAP notes should be written promptly to prevent a break or mixture of client record information.

2. Avoiding Common Errors

Minimize errors in SOAP notes to prevent misinterpretations. Avoid vague statements and focus on specifics. For instance, replace "client feels better" with "client reports a 50% reduction in pain after medication administration." Pay close attention to detail when documenting signs, symptoms, investigations, and treatment plans.

Refrain from inserting personal opinions or assumptions into the notes; let the data speak for itself. Additionally, ensure that any unresolved issues, pending tests, or follow‑up actions are clearly documented to maintain continuity of care.

3. Ensuring Compliance with Regulations

SOAP notes must meet legal and regulatory standards to protect both clients and providers. Abide by HIPAA or other relevant laws to preserve the clients’ anonymity. It is advisable not to incorporate excessive identifiable information.

SOAP Note Abbreviations Explained

Here’s a breakdown of common abbreviations used in mental health counseling SOAP notes:

SOAP Notes With Twofold

Twofold Health streamlines SOAP note documentation for healthcare professionals across specialties. Here’s how it improves your workflow:

Prebuilt SOAP Templates

Choose from ready‑to‑use templates designed for general healthcare and specialty practices, including streamlined formats that combine sections.

Customizable Documentation

Modify existing templates or create custom formats tailored to your field. Add, remove, or reorder sections to align with specific workflows.

AI-Powered Note Creation

Twofold’s AI generates draft SOAP notes from session data, checks for missing details, and provides actionable insights to enhance treatment planning.

Efficiency Features

Save time with pre‑filled prompts, one‑click copying, and tools for managing multiple notes effortlessly.

Secure and Compliant

All documentation complies with HIPAA and other regulatory standards, ensuring patient information remains protected.

Twofold Health offers a fast, flexible, and secure solution for SOAP notes, helping healthcare providers focus on delivering quality care.

Conclusion

SOAP notes are crucial in healthcare settings as they provide a structured method for documenting a client’s condition. They not only enhance communication by simplifying the documentation process, but also ensure legal compliance. When healthcare professionals master the SOAP format and consistently apply its four components, it leads to higher‑quality care, improved client outcomes, and stronger collaboration among caregiving teams.