How to Write a SOAP Note (With Examples)

The SOAP note, Subjective, Objective, Assessment and Plan, is the most widely recognized documentation format across healthcare, which makes it a strong default when you coordinate with physicians or bill insurers. Here is how to write each section, with an example you can adapt.

1. Subjective

What the client reports, ideally in their own words: mood, symptoms, stressors and relevant life events.

Example: "Client reports feeling 'less on edge' this week and describes two nights of uninterrupted sleep. Notes ongoing tension with a sibling but denies any thoughts of self-harm."

2. Objective

What you observe or measure: appearance, affect, mental status and any standardized scores.

Example: "Alert and oriented, well groomed. Affect brighter than prior sessions, congruent with reported mood. GAD-7 = 8, down from 13."

3. Assessment

Your clinical interpretation: progress toward goals, working diagnosis and any change in risk.

Example: "Client demonstrating steady response to CBT for generalized anxiety; worry episodes are shorter and less frequent. No acute safety concerns."

4. Plan

Next steps: interventions, homework, referrals and the next appointment.

Example: "Continue weekly CBT. Assigned a worry-postponement exercise. Reassess GAD-7 in two weeks. Next session in one week."

Common mistakes to avoid

• Blurring Subjective and Objective, keep reported separate from observed.
• Copy-pasting last week's note; auditors look for session-specific detail.
• A Plan that does not tie back to the treatment goals.

Write SOAP notes automatically

NotedTherapy drafts a complete SOAP note from your session in your own clinical voice, ready to review and edit. Compare formats in our guide to SOAP vs DAP vs BIRP notes, or start a free trial.