How to Write SOAP Notes

9
min read

As Behavioral Healthcare Professionals, we leave graduate school feeling mostly prepared for our future careers as counselors. However, being trained on accurately documenting a session and/or completing progress is something college does not prepare us for.  

SOAP notes are intended with the purpose of capturing specific information about a client and certain aspects of the session.  One saying in behavioral health counseling  that’s always worth remembering is “If it isn’t documented, it didn’t happen”.  This stresses the importance of clear and concise documentation of a therapy session.  It’s a benefit for both the client and the counselor in order to capture their steps in their recovery.

Let’s  breakdown  SOAP note and brush up on our documentation:

(S)Subjective - Statement about relevant client behavior or status.

  • This is where you as the clinician enter information regarding the client’s chief complaint, presenting problem, and any other relevant information including direct quotes from the client.  Might also include personal or medical issues that may impact or influence the client’s day-to-day routine.
  • Contains a complete account of the client’s description of symptoms
  • Progress from the last encounter

Content to include:

Jon states: “I didn’t sleep well last night and I’ve felt irritable all day”.  We discussed his sleeping patterns and current stressors as possible reasons for his lack of sleep.

Jon reports bouts of depressive episodes and crying spells in the past week & says “I just start crying out of nowhere.  I don’t know where it’s coming from”.  During last week’s session, I remember Jon mentioning the anniversary of his mother’s death; we talked about this being a possible trigger for his current emotional state. 

Content to avoid: 

Do not include statements without supporting facts; statements such as “Client was willing to participate” is an opinion until you provide facts to support this observation. Consider only information that you feel is relevant and statements from the client, loved ones, or teachers that can be attributed to your client’s mood, motivation, awareness, and willingness to participate. 

When making subjective statements, include pertinent evidence. For example: “Client appears nervous as evidenced by fidgeting of hands, not maintaining eye-contact, and shortness of breath during our session.”


(O)Objective - Observable, quantifiable, and measurable data.

  • This part of the note includes factual documentation about the client including a client’s diagnosis, behavioral and/or physical symptoms, appearance, orientation, and mood/affect.  
  • How the client presented themselves (affect, behavior, eye-contact, nervousness, talkativeness) based on your observations
  • verbal/non-verbal
  • Body posture
  • Affect when discussing certain topics or issues

Content to include:

  • Physical, interpersonal, and psychological you’re observing
  • General appearance
  • Affect & behavior 
  • Nature of therapeutic relationship
  • Client’s strengths
  • Client’s mental status
  • Client’s ability to participate in the session
  • Client’s responses to the process
  • Written materials such as reports from other providers, psychological tests, or medical records can be included here (if applicable) 

Examples:  

  • Jon is alert: oriented to time and place & he actively participates during today’s session as indicated by positive responses and prompt replies.
  • Jon displays a mostly flat/blunted affect, hygiene is below baseline.  He takes several seconds to respond to questions I ask him during the session.  


Content to avoid:

  • General statements without supporting data 
  • Avoid assumptive statements pertaining to behavior
  • Labels
  • Personal judgements
  • Value-laden language
  • Opinionated statements (personal rather than professional opinions)
  • Words/phrases that have negative connotations and/or are open to personal interpretations (Ex: uncooperative, obnoxious, normal, drunk, spoiled)

Example:  

  • “Jon arrived drunk and was acting rude & obnoxious during today’s session.”

(A)Assessment- Assimilate S. and O. section.

  • Use professional acquired knowledge to interpret information given by the client during the session.  
  • Implement clinical knowledge and understanding (DSM/Therapeutic Model, identify themes or patterns) 
  • Update/include DSM criteria observations exhibited by client

Content to include: 

  • Client appeared unusually disheveled, exhibited excessive anxiety and worry toward partner's threat of abandonment and denial of autonomy.  CL presented an abundance of guilt and shame due to infidelity from their partner. Counselor feels this may contribute to the immoderate emotion response and intemperate consumption of alcohol CL is currently experiencing.
  • Client appears to continue experiencing anxiety
  • Client continues to experience family related stressors
  • Client exhibited signs of moderate depression
  • Client anxiety has increased in severity and appears to meet the criteria for GAD

Content to avoid: 

  • Repeating your previous statements in the S. O. section.  In this section you will want to include: progress, regression, or plateau of client progress. 


(P) Planning- 

(Plans for Client) Outline the next course of action as far as treatment plan, given the preceding information gathered during your session.

  • Focus on your next steps for the upcoming session.  Keep in alignment with your overall treatment plan without reinstating it in full in this section.
  • Focuses on things both parties have agreed to 
  • Note nutritional, physical, medical attributes that will contribute to client’s therapeutic goals should be mentioned
  • Note progression/regression client has made in treatment
  • Implementation 
  • Should be aligned with assessment and direct

Examples of content to include: 

  • Counselor will introduce designated assessments to assess the client's focus and uncontrollability.
  • Focus on client's reported symptoms or issues in daily functioning, if applicable. (frequency, duration, intensity, and type).
  • Counselor will continue to build trust and confidence with client to allow space for exploration of previous events similar to current stressors, and explore those conclusions.
  • “Client will consult with a licensed nutritionist, in order to create a healthy diet and lifestyle plan.”
  • “Client will begin yoga classes at local gym.”
  • “Client is committed to attending group therapy sessions for eating disorders.”

Content to avoid: 

  • Restating overall treatment plan, instead of goals for the next session
  • Unrealistic, measurable goals to be accomplished before the client’s next session.


Tips for completing SOAP notes:

  • Consider how the patient is represented: avoid using words like “good” or “bad” or any other words that suggest moral judgments
  • Avoid using tentative language such as “may” or “seems” 
  • Avoid using absolutes such as “always” and “never”
  • Write legibly 
  • Use language common to the field of mental health and family therapy 
  • Use language that is culturally sensitive 
  • Use correct spelling/grammar
  • Proofread your notes
  • Write your note as if you were going to have to defend its contents.
  • Use clear and concise language. Avoid using slang, poor grammar or odd abbreviations.
  • When quoting a client, be sure to place the exact words in quotation marks.
  • Keep your notes short and to-the-point. Be clear and complete. Avoid expanding beyond what is required for each section.

And remember:  there is no such thing as the perfect progress note!

Documentation Requirements Specific to Telehealth

Progress notes are also required for virtual/telehealth sessions. Below are the required components to include in those notes.

  • date of service
  • start and stop time
  • the date of the next session
  • the interventions
  • mental status
  • statement that the service was provided using tele-health or telephone. Example: “Met with client via video conference.”
  • location of the provider: home vs. office
  • Provider should be conducting therapy from the office address that’s on file with the insurance company 
  • If conducting a family session: document who is present. Example: “Rita and her mother are present for this session.”


**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

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