How to Write a SOAP Note: A practical guide for mental health providers
The SOAP note format remains one of the most widely used methods for documenting therapy sessions, offering a clear structure that supports clinical reasoning, continuity of care, and administrative compliance. Originally developed in medical settings, the format translates effectively into mental health practice and helps organize complex clinical information in a concise and meaningful way.
In this post, we’ll walk through how to write a psychotherapy SOAP note, with practical prompts and suggestions to guide each section. Whether you’re in private practice or part of a larger healthcare setting, these cues can help ensure your documentation is clinically sound and aligned with current standards.
SOAP Note Overview
S = Subjective
O = Objective
A = Assessment
P = Plan
This format encourages the clinician to separate the client’s own reported experience (S) from observable information (O), while also integrating clinical formulation (A) and next steps (P). Below is a breakdown of each section, along with a guiding question clinicians can ask themselves when writing.
Demographic and Administrative Information
As with any progress note, start with the client’s name, date of the session, CPT and diagnostic codes, start/end times, location, session format, fee, and payment status.
Clinician Prompt:
💡 What are the key administrative and identifying details of this session?
After that preliminary section, we can then start in on writing our SOAP note…
1) Subjective
This section captures what the client reports about their own experience—emotionally, cognitively, and situationally. It may include their self-described affective state, the themes they bring forward, and how they are interpreting or coping with current difficulties. While quotes can be included sparingly to convey meaning, most of this section should paraphrase the client’s report.
Clinician prompt:
💡 What did the client share about how they’re feeling, what they’re facing, or what they’re thinking about this week?
Examples:
“The client reported feeling increasingly anxious when preparing for work-related meetings.”
“Client described ongoing sadness and hopelessness: ‘It’s like I can’t find the point of anything anymore.’”
“The client reported a positive experience reconnecting with a sibling after months of silence.”
2) Objective
In contrast to the Subjective section, the Objective section includes observable and measurable information gathered during the session. This may include the client’s physical appearance, emotional presentation, behavior, and any mental status observations. This section is best documented using neutral, descriptive language with reference to observable indicators.
Clinician prompt:
💡 What did I observe during the session that another clinician or trained observer would likely perceive as well?
Examples:
“Client appeared disheveled and fatigued; speech was slowed and response latency increased.”
“Observed affect was congruent with content; tearful when discussing recent loss.”
“Client maintained good eye contact, posture was upright, and mood appeared elevated throughout the session.”
3) Assessment
Here, you integrate the subjective and objective information into a clinical formulation. This might include diagnostic impressions, clinical impressions, functional assessments (e.g., using WHODAS or a GAF-like estimation), relevant biopsychosocial considerations, and any key clinical issues or developments that emerged. This is also the place to summarize any assessment tools administered during the session. Some clinicians also choose to put their therapeutic interventions in this section, as well as the client’s response to those interventions (more typically however interventions are documented in the Plan section below).
Clinician prompt:
💡 How do I clinically understand what’s happening for the client based on today’s session? What themes, risks, or patterns are important to note?
Examples:
“Client’s presentation remains consistent with symptoms of generalized anxiety disorder, with recent increase in avoidant behavior.”
“Functioning remains moderately impaired, particularly in interpersonal relationships and role performance at work.”
“No new safety concerns emerged; client denied suicidal ideation and continues to utilize coping skills discussed in prior sessions.”
4) Plan
This section documents your therapeutic interventions and the client’s response. It also outlines the next steps in treatment: goals, time frame, assigned tasks, and any changes in direction. This is where you should clearly include statements that support medical necessity—describing why treatment is needed, what functional impairments exist, and how continued therapy addresses those needs.
Clinician prompt:
💡 What did I do in session today, how did the client respond, and what is the plan going forward—including clinical rationale for ongoing care?
Examples:
“Provided psychoeducation on cognitive distortions and guided a cognitive restructuring exercise.”
“Client responded positively to mindfulness-based grounding strategies and agreed to practice them daily.”
“The ongoing treatment plan includes therapeutic work on building and maintaining self-care, and building greater social and interpersonal skills.”
Medical Necessity Note: Be sure to include a phrase or two that justifies ongoing treatment, such as:
“Continued psychotherapy is medically necessary to address impairments in emotional regulation, occupational functioning, and persistent symptoms of anxiety”.
“Treatment remains focused on reducing symptom severity and improving functional coping strategies.”
“Continued psychotherapy is medically necessary to address ongoing emotional dysregulation and functional impairments in occupational and social domains.”
Signature
Finish the note with your official signature line, credentials, and date. Ensure all documentation meets your local professional and legal standards.
Some Final Thoughts
This structure offers flexibility while maintaining clinical rigor. Over time, writing SOAP notes in this way can help support clearer clinical thinking, appreciation of treatment progress, and stronger treatment records more generally.
The level of detail, tone, and content may vary depending on your clinical setting, licensing requirements, or documentation policies. When in doubt, refer to your regulatory body’s guidelines and any applicable organizational policies. If you’re billing to insurance or working with third-party payers, ensure that your SOAP notes clearly demonstrate medical necessity and document treatment progression.
At Note Designer, we offer a thoughtfully structured SOAP note template designed specifically for mental health providers. It includes customizable sections, built-in drop-downs, and a rich library of professionally written content to help you document efficiently and thoroughly—including clear, editable statements that support medical necessity. Whether your approach is CBT, psychodynamic, Trauma-Focused or integrative – Note Designer has you covered (we support over 20 different treatment approaches) and you can also tailor the template to fit your clinical style and workflow with ease. In addition to our SOAP note for individual therapy, our platform also offers dedicated SOAP note templates specifically for Child-Family Therapy and for Addictions Counseling. Note Designer also includes an optional AI-Rewrite feature that can help polish your note once it’s drafted. Whether you want to refine the phrasing, improve flow, or ensure a more professional tone, the AI-Rewrite offers gentle editing support — always keeping your clinical voice intact. It’s there when you need it, and completely optional.
Note Designer also offers an AI-Auto Note option: simply enter a few key statements or select from our built-in content drop-downs, and the AI will generate a complete progress note based on your specifications—whether SOAP, BIRP, DAP, SIRP, GIRP, or other formats. You can customize note style, pronouns, and level of elaboration to match your clinical voice and workflow.
By Patricia C. Baldwin, Ph.D.
Clinical Psychologist
Co-Founder Note Designer Inc.
Author of
Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2nd Edition – updated and expanded); 2023.
👩🏻💻 This blog post is derived from Chapter 4 of Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2nd Edition- updated and expanded); 2023
© 2025 Patricia C. Baldwin. All rights reserved.
This blog post is the intellectual property of Patricia C. Baldwin and may not be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the author. Brief quotations may be used with appropriate citation and link to the original source.
