SOAP note for therapy documentation, what belongs in Subjective, Objective, Assessment, and Plan, and review a practical example." >
Clinical documentation guide

How to Write a SOAP Note

SOAP notes organize clinical documentation into four sections: Subjective, Objective, Assessment, and Plan. This guide explains what belongs in each section and includes a practical therapy example.

SOAP stands for Subjective, Objective, Assessment, and Plan.

The format separates what the client reports, what the clinician observes, the clinical interpretation, and the next steps in treatment.

What is a SOAP note?

A SOAP note is a structured clinical documentation format that helps organize information from a treatment encounter. Each section serves a different purpose and helps separate reported information from observed information and clinical interpretation.

1. Subjective

The Subjective section contains information reported by the client, including symptoms, concerns, experiences, changes since the previous visit, and other clinically relevant self-reported information.

Subjective information may include

  • Client-reported mood or symptoms
  • Changes in sleep, functioning, relationships, or stress
  • Client concerns or treatment priorities
  • Relevant statements about progress or setbacks
  • Client-reported response to coping strategies or homework

2. Objective

The Objective section describes information observed by the clinician during the encounter.

Objective information may include

  • Behavior and level of engagement
  • Observed affect or presentation
  • Speech or communication patterns
  • Clinically relevant behavior during the session
  • Interventions performed or skills practiced
Tip:

Keep the Objective section focused on observations and session events rather than assumptions that belong in the Assessment section.

3. Assessment

The Assessment section contains the clinician's interpretation of the subjective and objective information.

This may include progress toward treatment goals, response to interventions, current clinical presentation, changes in symptoms, and other clinically relevant impressions.

4. Plan

The Plan section documents what happens next in treatment.

  • Next session focus
  • Continued interventions
  • Homework or coping practice
  • Follow-up actions
  • Referrals or coordination of care when appropriate

SOAP note example

The following fictional example demonstrates how the four sections can work together.

Subjective

Client reported increased anxiety related to a recent job search and described difficulty sleeping on several evenings because of repetitive worries about finances and employment. Client reported using a breathing exercise twice during the week and stated it helped reduce the urge to repeatedly check email.

Objective

Client was attentive and engaged throughout the session. Affect was consistent with reported anxiety. Client participated in review of coping strategies and practiced identifying a more balanced response to an automatic negative thought related to employment.

Assessment

Anxiety remains elevated in response to employment uncertainty, particularly during evening hours. Client demonstrates increased awareness of the relationship between worry, repeated checking behaviors, and sleep disruption. Client appears receptive to cognitive and behavioral strategies.

Plan

Continue cognitive restructuring and behavioral strategies for evening rumination. Client will practice a brief grounding exercise during anxiety spikes and limit work-related email checking during the final 30 minutes before bedtime. Review adherence and barriers at the next session.

SOAP note vs. DAP note

SOAP uses four sections and separates subjective client reports from objective observations. DAP uses three sections and typically combines much of the session information into a broader Data section before separating Assessment and Plan.

The appropriate format depends on the clinician's workflow, organizational requirements, payer expectations, and other applicable documentation standards.

Common SOAP note mistakes

  • Mixing subjective reports with objective observations
  • Writing an overly detailed transcript instead of a clinical summary
  • Repeating the same information in every section
  • Using vague Assessment language that does not show clinical reasoning
  • Creating a Plan that does not connect to the treatment encounter

Using an AI SOAP note generator

AI-assisted clinical documentation can help organize therapy session content into a SOAP structure, reducing the need to begin every note from a blank page.

Generated documentation should still be reviewed and corrected by the clinician before being used as part of the clinical record.

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Turn session content into structured SOAP drafts.

ClariteNote helps therapists organize recorded, uploaded, or typed session information into clinical documentation for review.

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