SOAP stands for Subjective, Objective, Assessment, and Plan. This highly structured progress note format is widely used across medical, behavioral health, and multidisciplinary care settings.
When SOAP Notes Are Helpful
SOAP notes are especially useful when documentation must clearly separate the client’s report, observable information, clinical interpretation, and next steps. The format can support continuity of care, interdisciplinary communication, insurance review, and compliance requirements.
SOAP Sections
Subjective (S)
Document what the client reports about symptoms, emotions, experiences, functioning, concerns, and progress.
Include:
- Relevant client statements or concise quotations
- Reported symptoms and changes since the previous session
- The client’s perception of progress, barriers, or stressors
- Information about functioning at home, work, school, or in relationships
Objective (O)
Document observable, measurable, and factual information from the session.
Include:
- Appearance, behavior, affect, speech, engagement, and orientation when relevant
- Observable responses during the session
- Screening or assessment results when administered
- Interventions or structured activities completed
Assessment (A)
Document the clinician’s interpretation of the subjective and objective information.
Include:
- Clinical impression of current symptoms and functioning
- Progress toward treatment goals
- Relevant patterns, barriers, strengths, or risk considerations
- Medical necessity and rationale for continued treatment when appropriate
Plan (P)
Document the agreed upon next steps.
Include:
- Focus of the next session
- Skills, homework, or actions to practice
- Follow up, referrals, coordination, or monitoring needs
- Frequency of treatment or the next appointment when relevant
Reusable SOAP Template
S — Subjective
Client reported [current symptoms, concerns, experiences, or changes]. Client described [impact on functioning]. Client identified [progress, barriers, strengths, or relevant context].
O — Objective
Client presented as [observable appearance, affect, behavior, speech, and engagement]. Therapist observed [relevant objective information]. Session included [interventions, assessments, or activities].
A — Assessment
Client’s presentation remains consistent with [clinical formulation or treatment focus]. Current symptoms are affecting [functional areas]. Client demonstrated [progress, insight, response, strengths, or barriers]. Continued treatment remains appropriate to address [clinical needs].
P — Plan
Continue treatment focused on [goal or clinical need]. Client will practice [skill or action] before the next session. Therapist will [planned intervention, follow-up, coordination, or monitoring]. Next session will address [topic or goal].
Brief Example
S — Subjective
Client reported increased worry related to work responsibilities and difficulty disengaging from anxious thoughts in the evening. Client stated that paced breathing was helpful on two occasions but was difficult to remember during periods of high stress.
O — Objective
Client appeared alert and engaged with mildly anxious affect. Speech was clear and organized. Therapist used cognitive restructuring and guided rehearsal of a grounding strategy.
A — Assessment
Anxiety continues to interfere with sleep and concentration. Client demonstrated increased awareness of worry patterns and partial progress in using coping skills independently. Continued treatment is indicated to strengthen skill generalization and reduce functional impairment.
P — Plan
Client will practice the grounding strategy once daily and track situations in which worry increases. Continue CBT interventions focused on cognitive flexibility and anxiety management at the next session.
Use factual, clinically relevant, and non-identifying language. Adapt this template to applicable laws, payer requirements, employer policies, professional standards, and the needs of the individual client.