Therapy note template

SOAP Note Template

A SOAP note organizes a clinical encounter into the client’s report, observable information, clinical interpretation, and the next treatment steps. The format helps keep reported experience separate from observation and formulation.

Copy the templateWrite better section prompts

Best for

  • Individual psychotherapy progress notes
  • Practices that want a familiar, widely recognized clinical structure
  • Clinicians who want clear separation between report, observation, and interpretation

What makes this format different

SOAP separates what the client says (Subjective) from what the clinician observes or does (Objective). Clinical meaning belongs in Assessment, while future actions belong in Plan.

Copy and adapt

Blank SOAP template

Subjective
[Client-reported concerns, symptoms, emotions, stressors, progress, or setbacks.]

Objective
[Observable behavior, relevant mental status findings, and interventions used.]

Assessment
[Clinical formulation, symptom severity, functional impact, response to treatment, and progress toward goals.]

Plan
[Next interventions, between-session practice, referrals, follow-up, and next-session focus.]

Adapt required fields to your license, setting, payer, EHR, jurisdiction, and organization policy. Do not use a generic template as a compliance checklist.

Prompt architecture

How to write each section prompt

A useful section prompt tells the writer what evidence belongs in the section, where the information comes from, and what must not be inferred. The prompts below are adapted from BeeThere’s production note-format definitions.

1

Subjective

Capture the client’s perspective without blending in clinician interpretation.

Section prompt

Document the client’s self-reported experiences, including presenting concerns, symptoms, emotions, stressors, and perceived progress or setbacks. Attribute information to the client and do not add therapist observations or interpretation.

Include

  • What the client reported
  • Changes since the last session
  • Impact on daily functioning

Guardrail

Do not place appearance, behavior, diagnosis, or your clinical conclusions here.

Fictional section example

The client reported more frequent worry about work deadlines this week and described difficulty falling asleep on three nights. They said paced breathing helped them settle before one meeting.

2

Objective

Record observable facts and the interventions actually delivered.

Section prompt

Document observable behaviors, relevant mental status findings, and therapeutic interventions provided during the session. Use factual, measurable language and avoid unsupported clinical interpretation.

Include

  • Observable presentation
  • Interventions used
  • Participation or measurable findings

Guardrail

Avoid labels such as “manipulative” or “unmotivated” that are not direct observations.

Fictional section example

The client arrived on time, maintained attention, and spoke at a rapid rate when discussing work. The therapist used cognitive restructuring and rehearsed paced breathing; the client completed both exercises.

3

Assessment

Explain the clinical meaning of the reported and observed information.

Section prompt

Provide a concise clinical formulation of the current presentation, including symptom severity, functional impact, treatment response, progress toward goals, and barriers. State the rationale for continued treatment only when supported by the note.

Include

  • Synthesis of S and O
  • Progress or lack of progress
  • Clinical rationale

Guardrail

Do not introduce a new diagnosis, risk level, or fact that was not assessed or documented.

Fictional section example

Anxiety remains moderate and continues to affect sleep and work concentration. The client is beginning to use regulation skills outside sessions but still needs support applying cognitive strategies during higher-stress situations.

4

Plan

Turn the assessment into concrete next steps.

Section prompt

Document the treatment plan moving forward, including interventions to continue, homework or skill practice, goals for the next session, referrals, and follow-up. Include only plans discussed or clinically indicated by the documented treatment.

Include

  • Frequency or follow-up
  • Specific between-session practice
  • Next clinical focus

Guardrail

Avoid vague language such as “continue treatment” without naming the intended action.

Fictional section example

Continue weekly CBT. The client will complete two thought records and practice paced breathing before one work meeting. Review sleep and skill use at the next session.

Fully fictional

Completed SOAP example

The example below is entirely fictional. It demonstrates concise documentation for an adult outpatient session focused on anxiety and work stress.

Subjective

The client reported more frequent worry about work deadlines this week and described difficulty falling asleep on three nights. They said paced breathing helped them settle before one meeting.

Objective

The client arrived on time, maintained attention, and spoke at a rapid rate when discussing work. The therapist used cognitive restructuring and rehearsed paced breathing; the client completed both exercises.

Assessment

Anxiety remains moderate and continues to affect sleep and work concentration. The client is beginning to use regulation skills outside sessions but still needs support applying cognitive strategies during higher-stress situations.

Plan

Continue weekly CBT. The client will complete two thought records and practice paced breathing before one work meeting. Review sleep and skill use at the next session.

Quality check

Common documentation mistakes

  • Mixing clinician observations into Subjective
  • Listing interventions without documenting the client’s response
  • Repeating the same facts in every section
  • Adding unsupported diagnoses or risk conclusions
  • Using a Plan that is not connected to the Assessment

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