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Compliance and documentation

How to write SOAP notes

Here’s how SOAP notes can help you write better, faster notes — and effectively document your work as a clinician.

December 21, 2023 • Updated on July 24, 2026

18 min read

Writing in a journal is easy: There are no rules, and it’s only for yourself. But progress notes come with a different kind of pressure. While it might be intimidating to translate your care into a note, it’s simpler than it seems. Especially when you’re using a template like a SOAP note. Here’s how SOAP notes can help you write better, faster notes — and effectively document your work as a clinician.

Key takeaways

  • The four sections of a SOAP note are: subjective, objective, assessment, plan.
  • SOAP notes are clearly structured, ensuring thorough and compliance-friendly documentation.
  • While their structure is consistent, SOAP notes’ content can be tweaked for different therapy types.
  • Headway’s AI-assisted notes, templates, and more makes compliant therapy documentation easy.

What is a SOAP note?

SOAP notes are a specific format for writing progress notes as a behavioral health clinician. They contain four primary sections, represented by its acronym: 

  • Subjective
  • Objective
  • Assessment
  • Plan

If you’re using a SOAP note template and filling out every section as directed, you should feel good about how your notes stack up to compliance expectations. Each section of a SOAP note is designed to help you document the most critical aspects of your session for compliance with insurance billing, including elements of a mental status exam and risk assessments.

How long is a SOAP note?

A SOAP note is typically concise, usually ranging from two to four paragraphs in length. The specific length can vary depending on complexity of the patient's condition, but therapists aim to be thorough yet succinct.

A SOAP note’s holistic approach naturally encourages you as a provider to collect comprehensive insight about your client and their treatment. And because SOAP notes are widely recognized and used in many different healthcare settings, other care providers can easily recognize and review your mental healthcare records to provide continuity of care for your clients. 

Headway’s built-in note-taking feature uses a SOAP note template, and includes one-click check boxes to help you fulfill the mental status exam and risk assessment on your notes. 

What are the compliance benefits of using the SOAP notes format?

A SOAP note’s clear and consistent format ensures that nothing falls through the cracks. As long as you thoroughly fill out each section of the note, you’ll naturally spell out the client’s presenting problem and status, your assessment of their condition, and your plans and rationale for treatment. All of that information comes in handy when submitting insurance claims, since payers will expect to see relevant patient information as well as justification for services rendered.

Plus, keeping detailed records through your SOAP notes creates an important paper trail in case of unlikely worst-case scenarios like legal disputes.

Use Headway’s progress note templates

While there are many options for documentation, Headway's in-product templates are designed to make note-taking fast and efficient, all while helping to take out the guesswork. 

Headway’s documentation templates are built from the ground up to meet insurance standards, so fewer important details fall through the cracks. We’ve also harnessed the power of AI to make note-taking quicker than ever, allowing you to turn a short session summary into a full progress note in a snap. Meanwhile, linkage between notes and claims streamlines the billing process, ensuring you get paid on time, every time. In short, we’re here to simplify every aspect of the documentation process. Plus, our templates are included at no additional cost for Headway providers.

Explore our session notes feature

How to write SOAP notes

As you sit down to write a SOAP note, reflect on your session and allow the four sections of the note template to guide you to document the most important aspects of your client’s current state and the progression of your treatment. 

Subjective

The subjective section is where you document what your client is telling you about how they feel, their perceptions, and the symptoms.

It’s most important to document the things that relate to the client’s diagnosis. “For example, if your client is depressed, what’s telling you that they’re depressed?,” says Natalia Tague, a licensed counselor in Virginia. “The subjective section might include that the client says they've been crying every day, that they can't sleep, or that they've lost their appetite.”

Many providers elect to include a direct quote from the client in the subjective section of their SOAP notes, which helps demonstrate to insurers that the session was unique and veritable.

Pro tip: Be precise. Don’t just write that your client “is depressed” or “feels depressed.” Spell out exactly what your client said to support that statement.

Objective

The objective section should include the therapist's observations, including measurable, observable data.

Consider what you’re seeing in the session that reflects what’s going on with the client in that moment. 

“Literally: What are you seeing?,” says Tague. “It’s things like: My patient's crying while we speak, they have trouble making eye contact, they seem disheveled, or they look like they haven't showered in a few days.”

This is also the section where you document the therapeutic interventions and modalities used during the session. Here are a few sample phrases:

  • “Utilized Cognitive Behavioral Therapy (CBT) to challenge the client's negative self-talk.”
  • “Practiced a 5-minute mindfulness breathing exercise to address reported anxiety.”
  • “Explored family dynamics using a genogram.”
  • “Provided psychoeducation on the 'fight-or-flight' response.”

Pro tip: Don’t let subjective content or clinical assessment creep into this section. Everything should be verifiable, observable, and/or measurable. If you’re unsure, ask yourself: “Could someone reasonably disagree with what I’m writing?”

Assessment

The assessment is the therapist's professional evaluation of the client’s condition, as captured in the subjective and objective sections. It should include their diagnosis, progress, risk assessment, formulation of the situation, and a review of the treatment plan.

In other words: This is where you should sum up the first two sections into a consideration of what’s going on with your client overall.

“The assessment is really just: What’s happening here?,” says Tague. “What is all of this telling you about the bigger picture: Are they getting better? Are they getting worse? Has there been a drastic change?”

Additionally, this section should analyze the client's response to the interventions applied during the session. Example phrases include:

  • "Client responded positively to cognitive restructuring, demonstrating an initial ability to identify alternative thoughts."
  • "The client appeared to have difficulty engaging with the guided imagery exercise, suggesting this may not be the preferred modality.

Pro tip: There should be a clear thread linking the subjective, objective, and assessment sections of a SOAP note. Don’t leap to a conclusion — like a new diagnosis — that can’t be supported by the information in the first two sections.

Plan

The plan section is where you document your intended actions moving forward. It includes treatment strategies, therapeutic goals, recommended interventions, and any necessary adjustments to the client's treatment plan.

It’s the future-looking piece of the care puzzle: The client has told you what’s going on. You’ve said what you’re observing. You put those two together into an assessment. And now it’s time to plan for the care you want to provide in future sessions.

“You might write that we’re going to meet weekly. Or we’re going to move to meet monthly because they seem to be doing okay. Another part of it might be saying: I think we need to process more of these triggers and build out some coping strategies,” says Tague. “So the plan is just: Based on your assessment, where do you want to go next?”

Pro tip: For both care planning and compliance reasons, your plan section should be as specific as possible. Frameworks like SMART goals can be helpful here.

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SOAP notes templates you can use today

When it comes to progress notes, templates help you work smarter, not harder. Headway providers enjoy access to free documentation templates, supercharged by AI note-taking assistance. Or, you can use the SOAP note template below as a jumping off point.

Client:

Date:

Session type/length:

Diagnosis/presenting concerns (as applicable):


S: Subjective

  • Client status (mood, symptoms, problems, successes, worries):
  • Client quotes demonstrating status:

O: Objective

  • Clinician observations (affect, behavior, physical appearance, speech style):
  • Measures and assessment scores (if applicable):

A: Assessment

  • Diagnosis:
  • Clinical assessment (change in status, symptom progression):
  • Progress toward goals and/or obstacles blocking progress:
  • Risk and safety assessment (if relevant):

P: Plan

  • Plan and goals for future treatment, including treatment plan adjustments (if applicable):
  • Recommended interventions:
  • Coordination/referrals and homework assigned (if any):
  • Next session date/frequency:

SOAP note example

It’s important that SOAP notes, or notes in any template style follow the requirements of a progress note, such as including session details like the start and stop time and place of service. Here’s an example of how to style one:

SOAP note example for therapy

Client Full Name: Connor Client

Client Date of Birth: 2/2/1992

Date of Service: 7/10/2023

Exact start time and end time: 1:33 pm – 2:30 pm: 57 mins

Session Location: 123 Serenity Lane, Miami, FL 33143

Diagnosis: (F32.1) Major depressive disorder, single episode, moderate)


Subjective:

During the session, the client, Connor, reported a significant improvement in his overall mood since our last meeting. He has been consistently utilizing coping mechanisms that were previously discussed and has been making an effort to engage in activities that he once found enjoyable. He expressed that his depressive symptoms have decreased in both intensity and frequency. Additionally, Connor mentioned a recent family gathering where he felt more engaged and connected with his loved ones. This positive experience provided him with a sense of social support, which he believes contributed to his improved mood. However, Connor expressed ongoing concerns about his sleep patterns, noting occasional difficulty falling asleep and early awakenings.


Objective:

Client presents with no risk to self or others. Affect was bright and mood was euthymic. He actively participated in the session, showing improved eye contact and verbal expression. Therapist utilized a solution-focused approach to explore the client's recent successes, particularly the positive family gathering. The session also included behavioral activation, where the therapist and client collaboratively identified and scheduled three enjoyable activities for the upcoming week. Psychoeducation was provided on the connection between improved mood and social engagement. His body language suggested a decrease in overall tension compared to previous sessions.


Assessment:

Based on today's session, it is clear that Connor has made significant progress in managing his depressive symptoms. The combination of psychoeducation on coping strategies and increased engagement in pleasurable activities seems to be contributing positively to his overall well-being. His affect, mood, and verbal expression have all improved, indicating a positive response to therapy. However, Connor's ongoing concerns regarding his sleep patterns warrant further exploration. His difficulty falling asleep and early morning awakenings may indicate the presence of underlying stressors, which need to be identified and addressed.


Plan:

Moving forward, we will continue to reinforce and build upon effective coping strategies, such as mindfulness and behavioral activation. Additional attention will be given to Connor's sleep disturbances. We will explore potential triggers and stressors contributing to these issues and provide psychoeducation on sleep hygiene and relaxation techniques. The development of additional relaxation techniques to address his sleep concerns will also be considered. Connor's progress thus far is promising, and continued therapy sessions will aim to further improve his mood, manage his depressive symptoms, and address his sleep concerns.

SOAP note variations for different therapy types

The basic structure of a SOAP note never changes. But you should expect the content to vary depending on the services rendered.

A SOAP note describing a group therapy or couples counseling session would likely include observations about how participants interacted with one another or reacted to comments made by others in the session. By contrast, a SOAP note for an individual therapy session would be squarely focused on that one client and their treatment needs. Pediatric SOAP notes use the same four-part structure as regular SOAP notes, but they rely more heavily on observations, developmental context, and input from caregivers/teachers because children may struggle to articulate their symptoms.

Medication management SOAP notes also naturally contain different information than talk therapy progress notes. In addition to documenting any comments made specifically about medication efficacy, dosage, or side effects, SOAP notes for medication management appointments tend to be more objectively focused than their talk therapy counterparts. For example, you may spend extra time and attention detailing the client’s physical symptoms or psychological assessment scores.

To get a better sense for the subtle differences between SOAP notes for talk therapy and medication management, see the medication management example below.

SOAP note example for medication management

Client Full Name: Michael Martinez 

Client Date of Birth: 11/15/1988 

Date of Service: 3/18/2025 

Exact start time and end time: 2:15 pm – 3:12 pm: 57 mins 

Session Location: 450 Wellness Avenue, Chicago, IL 60611 

Diagnosis: (F41.1) Generalized anxiety disorder, (F33.0) Major depressive disorder, recurrent, mild


Subjective:

During the session, the client, Michael, reported continued difficulty managing his anxiety symptoms, particularly in work-related situations. He described experiencing increased worry about an upcoming presentation, accompanied by physical symptoms including tension headaches, racing heart, and difficulty concentrating. Michael noted that his medication (Sertraline 50mg daily) has provided some relief for his depressive symptoms, stating, "I don't feel as down as before, but the anxiety is still overwhelming at times." He mentioned using the deep breathing exercises we discussed previously but felt they were only partially effective when his anxiety peaked. Michael also shared that he has been sleeping approximately 6 hours per night, which is an improvement from our last session, though he still experiences early morning awakening around 4:30 am and difficulty returning to sleep.

Objective:

Michael presented to the session appropriately dressed and groomed. He was alert and oriented x4. His speech was normal in rate and volume but showed mild pressure when discussing work stressors. Eye contact was intermittent, improving as the session progressed. His affect was anxious but full range, congruent with content. No psychomotor agitation or retardation was observed. Michael's thought process was logical and goal-directed without evidence of psychosis, delusions, or obsessions. He explicitly denied current suicidal or homicidal ideation, intent, or plan. His PHQ-9 score was 9 (decreased from 13 at previous appointment), and his GAD-7 score was 14 (increased from 12), consistent with his self-reported symptoms. Michael demonstrated good insight into his condition and judgment appeared intact.

Assessment:

Based on today's session, Michael continues to meet criteria for Generalized Anxiety Disorder with symptoms that appear to be exacerbating in response to work-related stressors. His depressive symptoms show mild improvement with current medication management, suggesting positive response to Sertraline for the depressive component of his presentation. Michael's anxiety appears to be triggered primarily by performance situations, with associated physiological symptoms that impact his functioning. His partial response to relaxation techniques indicates the need for additional coping strategies. Sleep has improved but remains disrupted, which may be contributing to anxiety symptoms. Michael maintains good insight and shows continued motivation for treatment engagement.

Plan:

Moving forward, we will focus on enhancing Michael's anxiety management toolkit through the introduction of progressive muscle relaxation and cognitive restructuring techniques specific to performance anxiety. Medication management will continue with Sertraline 50mg daily with consideration for potential dosage adjustment at next psychiatric evaluation (scheduled for 4/1/2025). We will implement a sleep hygiene protocol with particular emphasis on managing early morning awakening. Michael will continue keeping his anxiety journal to identify patterns and triggers. We scheduled our next therapy session for 3/25/2025 at 2:15 pm, with an agreement to check in via secure messaging if anxiety symptoms significantly worsen before then. Michael verbalized understanding of and agreement with this plan.

Tips for writing SOAP notes

  • A good rule of thumb is to plan for 5 to 7 minutes to write your progress notes. Try to fit them in between sessions as you’re able, so you don’t end every day with hours of catching up. “Learning how to write concise but accurate notes is such an important skill, just for your own self care as a provider,” says Tague.
  • Comprehensiveness is more important than length. “I’ve seen notes that are literally two sentences per section and they’re great, and then there are notes with four or five sentences for each and they still haven’t covered what they needed to cover,” says Tague.
  • Don’t stress about documenting every single thing that happened in session. For insurance purposes, focus on including the information that supports the client’s diagnosis, and substantiates the ongoing need for treatment and the approach you are using. 

Common SOAP note mistakes and how to avoid them

SOAP notes should be clear, precise, succinct, and well-organized. Try to avoid falling into these common pitfalls as you put yours together:

  • Repeating content in multiple sections
  • Using vague language
  • Making clinical assessments that aren’t supported by subjective and objective data
  • Lacking specificity about future treatment plans and goals
  • Including details that are not relevant to the client’s diagnosis and continuing care

This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

SOAP vs DAP vs BIRP notes: What’s the difference?

There’s a lot of overlap among common progress note styles, but subtle differences can make certain formats better for certain situations. If you’re struggling to decide which note to use, consider these factors.

SOAPDAPBIRP
Use caseVersatile; commonly used for talk therapyVersatile; commonly used for talk therapyClinicians monitoring behavioral changes or efficacy of specific techniques
ProsHighly structured, aids compliance Can be shorter and more efficient than other stylesHelpful for therapists interested in specific outcomes or changes
ConsLots to cover; can be tricky to differentiate between objective and subjective dataLess structured, which can be challenging for new cliniciansMinimal attention on client’s self-reported feelings

Explore other therapy note frameworks

Curious about other frameworks beyond SOAP notes? Headway’s documentation resources dig into the different options:

Using AI SOAP notes to streamline care

If therapists aren’t careful, documentation can quickly become a major time-suck. Catching up on notes can eat into hours that would otherwise go to client care, strategic planning, or personal time. 

Enter: artificial intelligence note-takers. These tools can streamline the process, taking information provided by a clinician (or captured directly during a session, with client consent) and spinning it into a well-constructed SOAP note. Some tools are built specifically to generate notes that meet insurers’ standards, but clinicians must always review for accuracy and compliance.

Headway providers have access to Scribe, an AI note-taking assistant that:

  • Can turn a brief session summary into a compliant SOAP note 
  • Can draft a SOAP note directly from a session transcript
  • Works with existing SOAP note documentation templates
  • Can cut documentation time in half

"The quality is incredible,” says LMHC Leah Drizin. “I barely had to do any editing at all.”

SOAP notes FAQs

How long should a SOAP note be?

It varies, but often between two and four paragraphs.

Can I use SOAP notes for group therapy?

Yes, although the process is slightly different. The note should focus on the primary patient—the person whose insurance you’re billing — but also include information about group interactions and dynamics. Find more information about group therapy progress notes here.

Do SOAP notes need to be completed the same day?

While it’s not technically required, it’s ideal. It’s best to complete notes while the session details are fresh in your mind.

Do SOAP notes need to be different for telehealth sessions?

The basic structure is the same, but telehealth notes require some additional information. For example, you’ll need to note the platform used, where your client was physically located, and any technical issues that affected the session.

What's the difference between SOAP notes and psychotherapy notes?

Psychotherapy notes are essentially the private version of SOAP notes. They are for the therapist’s own use and are not part of the client’s medical record.

What should I write in the Assessment section if my client isn't making progress?

Your assessment doesn’t have to be positive. If you believe, based on the subjective and objective data you’ve gathered, that your client has either plateaued or regressed, you can also note that. If possible, identify factors that are blocking progress.

How detailed do SOAP notes need to be for different session lengths?

In general, the length of your note depends less on the length of the session, and more on the client’s status and the complexity of their case.

Headway streamlines compliant documentation

Headway’s team and tools are here to make everything about working with insurance companies (including compliance) as easy as possible. Focus on what you do best: caring for patients. 

With insurance credentialing, billing support, a robust EHR, and more, Headway helps your practice flourish. The best gift we can give you is more time. And with features including easy-to-use documentation templates built for in-network providers and AI-assisted note-taking, that’s exactly what you’ll get. 

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

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