SOAP Notes: Template, Examples & Download
A SOAP note is a progress note with four labeled sections: Subjective, Objective, Assessment, and Plan. It separates what the client reports from what you observe, then records your clinical judgment and the next steps. Therapists, counselors, and social workers use SOAP because insurers, agencies, and interdisciplinary teams already read it fluently.
Skip ahead to the blank SOAP note template if that’s all you need. It’s free, no email required, in PDF and DOCX.
What Does SOAP Stand For?
SOAP stands for Subjective, Objective, Assessment, Plan. Each letter is a labeled section. Subjective holds the client’s report, Objective holds your observations and any scores, Assessment holds your interpretation, and Plan holds what happens next. The structure comes from the problem-oriented medical record that Dr. Lawrence Weed introduced in the 1960s (Weed, 1968), and it has since spread to nearly every discipline that keeps a chart (Podder et al., StatPearls).
Section | What it captures | Example line |
|---|---|---|
S: Subjective | What the client reports: symptoms, concerns, history, homework, in their words. | “Client reports sleeping 4-5 hours nightly and ‘dreading Monday meetings.’” |
O: Objective | What you observe or measure directly: appearance, behavior, affect, speech, attendance, scores. | “GAD-7 score 14, down from 17. Leg bouncing through first half of session.” |
A: Assessment | Your clinical interpretation: progress, patterns, risk, working formulation. | “Presentation remains consistent with generalized anxiety; avoidance is narrowing.” |
P: Plan | Next steps with owners and timeframes: interventions, homework, referrals, reassessment. | “Daily thought record; introduce interoceptive exposure next session; appointment in one week.” |
S: Subjective
The client’s account: presenting concern, symptom reports, sleep and appetite, stressors, medication changes they mention, how the homework went. Quote sparingly and pick quotes that carry clinical weight. Everything here comes from the client’s point of view, which is why it stays Subjective even when it happens to be verifiably true.
O: Objective
What you can see, hear, count, or score: grooming, psychomotor behavior, affect and its congruence with content, speech rate and volume, orientation, punctuality, and results from measures like the GAD-7 or PHQ-9. A structured mental status exam cheat sheet habit fills this section in about a minute. In medicine this section holds vitals and labs. Therapy has neither, which is exactly why the section goes wrong so often. More on that below.
A: Assessment
Your clinical reasoning: progress against treatment goals, patterns across sessions, risk status, and the working formulation. Tentative language earns its keep here. “Presentation consistent with…” and “symptoms suggest…” survive an audit and a subpoena better than diagnostic pronouncements, and they respect the limits of a single session’s data.
P: Plan
The concrete next steps: homework assigned, interventions planned for next session, referrals, medication follow-up, safety planning, when you will reassess, and the date of the next appointment. “Continue therapy” is not a plan. Name the step, the owner, and the timeframe.
Subjective vs Objective: The Talk-Therapy Pitfall
The S vs O split trips up more counseling clinicians than any other part of the format. In a medical visit the boundary is physical: the patient’s story is Subjective, the exam and labs are Objective. In a therapy session, 45 of the 50 minutes is talk, so clinicians either leave Objective nearly empty or start sorting statements by whether they sound factual. Both habits produce weak notes.
The rule that fixes it: sort by source, not by truth. If the information came out of the client’s mouth, it is Subjective, even a checkable fact. If it came from your own senses or a scored measure, it is Objective, even when it concerns emotion, as long as you phrase it behaviorally.
Line from a session | Section | Why |
|---|---|---|
“I’ve been sleeping four hours a night.” | Subjective | The client reported it. You cannot verify sleep from your chair. |
Client arrived 15 minutes late, second consecutive session | Objective | You observed it directly. |
GAD-7 score of 14 | Objective | Measured, not reported impressionistically. |
“My doctor raised my sertraline to 100 mg.” | Subjective | A reported medication change. Record the source. |
Tearful when discussing brother; long pauses before answering | Objective | Behavioral observation, no inference. |
“Client seemed unmotivated” | Neither, as written | An inference. Describe the behavior in O, or interpret it tentatively in A. |
One more trap: “client appeared anxious” sits on the border because it smuggles a conclusion into an observation. “Leg bouncing, rapid speech, wringing hands” is the Objective version. Save “anxious” for the Assessment, where interpretation belongs.
How to Write SOAP Notes (Step by Step)
Write the sections in order and keep each one a few sentences. The format does the organizing for you.
Record the client’s report (S). Presenting concerns, symptoms, homework, changes since last session. Quote one or two lines that matter clinically.
Record what you observed (O). Appearance, behavior, affect, speech, attendance, and any measure scores. If a statement needs the client’s word to be true, it does not belong here.
Interpret (A). What do S and O together mean for progress, risk, and formulation? Phrase it tentatively and tie it to the treatment goals.
Commit to next steps (P). Homework, referrals, reassessment timing, next appointment. Each step gets an owner and a timeframe.
Reread as a stranger. Could another clinician continue care from this note alone? If not, the gap is usually a vague Plan or an empty Objective.
A first appointment usually calls for an intake note rather than a SOAP note; start from an intake form template and switch to SOAP from session two. For the wider documentation habit this sits inside (timing, frequency, retention), see how to write therapy progress notes.
SOAP Note Examples
The three examples below cover individual counseling, couples work, and social-work case management. All three describe fictional, composite clients. No real person, session, or record appears here. The first two are set in the US; the third is set in Ontario, Canada. Swap the credentials for your own state or province, the structure is identical everywhere.
SOAP Note Example: Individual CBT
Setting: telehealth session #8, 50 minutes, Licensed Professional Counselor, CBT for generalized anxiety.
Subjective: Client (29) reports “the Sunday dread is smaller this week” and estimates worry occupied “maybe two hours a day instead of most of the day.” Sleep onset roughly 30 minutes most nights, improved from about an hour. Completed 5 of 7 thought records; reports the work one was “hard to argue with.” Denies thoughts of self-harm. Objective: On time, adequately groomed, home office setting. Speech normal in rate and volume. Affect mildly anxious early in session, brightening in second half. GAD-7 today: 11, down from 14 two weeks ago. Engaged actively in restructuring exercise without prompting. Assessment: Symptoms continuing to trend down across self-report and GAD-7. Client is now generating alternative appraisals with less scaffolding than at session 5, suggesting the skill is consolidating. Work-performance worries remain the most rigid cluster. Presentation remains consistent with generalized anxiety; no change to risk status. Plan: Continue daily thought records targeting work worries specifically. Introduce a worry-postponement experiment next session. Re-administer GAD-7 at session 10. Next appointment in one week, same time.
SOAP Note Example: Couples Counseling
Setting: in-person session #4, 60 minutes, Licensed Marriage and Family Therapist, communication-focused couples work.
Subjective: Partner A reports two arguments this week, “shorter than usual,” and says the time-out signal “worked once, then we forgot it.” Partner B reports feeling “less ambushed” but says evenings still feel tense after A travels for work. Both deny any escalation to yelling or threats; both report completing the shared appreciation exercise twice. Objective: Both on time. Partners sat angled toward each other, a change from sessions 1-2. One demand-withdraw sequence observed at minute 20 (B pressed on travel schedule, A went quiet, arms crossed); pattern interrupted when therapist flagged it, and both re-engaged within a minute. No contempt markers observed this session. Assessment: The couple is using the de-escalation tools inconsistently but with early effect; the observed recovery from the demand-withdraw cycle in session is faster than at intake. Travel weeks remain the highest-friction context. No safety concerns indicated at this contact. Plan: Assign the time-out signal specifically for the two evenings after A’s next trip. Introduce speaker-listener structure next session. Revisit shared expectations about travel at session 6. Next appointment in two weeks due to A’s schedule.
SOAP Note Example: Social Work Case Management
Setting: community mental health agency, Ontario, Registered Social Worker (OCSWSSW), scheduled follow-up three weeks after hospital discharge.
Subjective: Client (52) reports mood as “flat but steadier” since discharge. States she has taken medication daily but has “eight days of pills left” and no prescriber follow-up booked yet. Reports food budget “runs out by the third week” of the month. Identifies her neighbor as a current support. Denies thoughts of self-harm since discharge. Objective: Attended on time, second consecutive kept appointment. Casually dressed, adequate grooming. Speech slowed but goal-directed; affect flat, congruent with reported mood. PHQ-9 today: 13, down from 19 recorded at discharge. Brought discharge summary as requested. Assessment: Early post-discharge stability with two concrete continuity risks: medication supply gap within eight days and recurring monthly food insecurity. Follow-through capacity is a strength (two kept appointments, documents brought as asked). Mood improving on measure and self-report; no indicators warranting escalation at this contact. Plan: Same day: fax discharge summary and consent to the community psychiatry clinic and request an appointment inside eight days; flag the medication gap on the referral. This week: submit food-bank registration and review provincial benefit top-up eligibility with client. Client to call pharmacy about a bridging supply, script provided. Next appointment in one week; re-administer PHQ-9 in two weeks.
Blank SOAP Note Template (Copy or Download)
The template below is free to copy, print, or adapt. No email address required. Download the fillable PDF and Editable DOCX.
SOAP PROGRESS NOTE
Client: ______________________ Date: ____________ Time: ____________
Clinician: ____________________ Session #: ________ Duration: ______
Setting (in person / telehealth): __________________________________
S: SUBJECTIVE
What the client reports: presenting concerns, symptoms in their words,
changes since last session, homework report. Quote sparingly.
Reported: _________________________________________________________
___________________________________________________________________
O: OBJECTIVE
What you observe or measure directly: appearance, behavior, affect,
speech, mental status findings, attendance, measure scores.
Observed: _________________________________________________________
Measures / scores (if any): _______________________________________
A: ASSESSMENT
Your clinical interpretation: progress toward goals, patterns across
sessions, risk status, working formulation. Use tentative language.
___________________________________________________________________
___________________________________________________________________
P: PLAN
Next steps with owners and timeframes: interventions, homework,
referrals, when you will reassess, date/focus of next session.
___________________________________________________________________
___________________________________________________________________
Signature / credentials: ________________ Date signed: ____________
If you would rather not fill this in by hand at 9 p.m., Klarify drafts the whole note from your session. More on that after the mistakes list.
SOAP vs DAP vs DARP: Which Format Fits?
All three formats end in Assessment-then-Plan reasoning. They differ at the front of the note: SOAP splits the client’s report from your observations, DAP merges them into one Data section, and DARP adds a dedicated Response section for intervention outcomes.
Format | Sections | The distinguishing move | Reach for it when |
|---|---|---|---|
SOAP | Subjective, Objective, Assessment, Plan | Separates report from observation | Insurers, agencies, or interdisciplinary teams expect the split |
Data, Assessment, Plan | Merges S and O into Data | Solo talk-therapy practice where nobody requires the split | |
Data, Assessment, Response, Plan | Gives the client’s response to intervention its own section | Intervention-heavy sessions where outcomes must stand out | |
BIRP | Behavior, Intervention, Response, Plan | Leads with observed behavior | Behavior-focused programs and community mental health |
If you write SOAP and the S vs O sorting slows you down with no payoff, DAP is the smaller note. If you keep losing track of how clients responded to interventions, DARP is the better upgrade than padding your Assessment.
Common SOAP Note Mistakes
Most weak SOAP notes fail in the same six ways, and five of them are sorting problems. Scan your note against the left column before you sign it.
Mistake | What it looks like | Fix |
|---|---|---|
Client statements in Objective | “Client only slept four hours.” filed under O | If it needs the client’s word to be true, it is Subjective. |
Inference dressed as observation | “Client was resistant today.” | Describe the behavior in O; interpret it tentatively in A. |
An empty Objective section | O reads “n/a” session after session | Affect, speech, attendance, and measure scores are all Objective. There is always something. |
Assessment that repeats S and O | The same facts restated with no interpretation | A answers “so what”: progress, patterns, risk, formulation. |
A vague Plan | “Continue weekly sessions.” | Name the next concrete step, its owner, and when you will reassess. |
Copy-forward drift | Last week’s note pasted in with a new date | Each note must reflect that session. Auditors look for repeated text. |
What Do Regulators Require?
No US board or Canadian college mandates the SOAP format. The rules govern what a record contains and how long you keep it, not which acronym organizes it. A complete SOAP note meets content expectations comfortably on both sides of the border; retention is where the differences live.
United States
HIPAA sets no retention period for clinical records. Retention comes from state law and your licensing board, which is why the answer to “how long do I keep notes” starts with your state (HHS, HIPAA FAQ 580). The APA’s Record Keeping Guidelines suggest retaining full records for seven years after the last service for adults, or three years after a minor reaches majority, whichever is later, absent a stricter state rule (APA, 2007). One distinction worth getting right: SOAP notes are progress notes, part of the designated record set. They are not “psychotherapy notes” as HIPAA defines that term; the extra protection in 45 CFR 164.501 covers only separate process notes kept apart from the rest of the record.
Canada
Canadian searchers often type “SOAP notes counselling” with two Ls; the spelling changes, the format doesn’t. What does change is the governing law and the retention clock. Health-information rules come from PHIPA in Ontario and PIPEDA federally, and record-keeping standards come from your college. CRPO requires Registered Psychotherapists to keep clinical records for at least ten years from the last interaction, or ten years after a minor client turns 18 (CRPO Professional Practice Standards, Section 5). Ontario social workers document under OCSWSSW’s standards, Principle IV: The Social Work and Social Service Work Record, which set their own retention and content expectations. Outside Ontario, OPQ, OTSTCFQ, BCACC, and the other provincial bodies each publish their own standard. When in doubt, the college’s document beats any template page, including this one.
Klarify Writes SOAP Notes for You
Klarify, an AI assistant for therapists in the United States and Canada, drafts SOAP notes from the session itself: in-person session audio, virtual meeting audio, session dictation, handwritten notes, an uploaded transcript, or an uploaded audio file. SOAP is one of its 20+ built-in formats, alongside SOAP v2, DAP, BIRP, and others, and if your agency uses a SOAP variant with extra fields, custom templates are included on every plan. Audio upload depends on your plan, so check the current details on klarify.ca. Klarify is fully HIPAA, PHIPA, PIPEDA, Quebec Loi 25, and GDPR compliant, offers BAAs on request, stores all data in Canada, and deletes session audio from storage within 14 days, or earlier if you set it. Every therapist also gets a free Psychology Today-style public profile hosted on klarify.ca, with built-in marketing features to attract clients.
The Objective section is the first casualty of a note written from memory hours later: the observations blur, so the section gets padded or skipped. A scribe that heard the session keeps S and O honest, because it can quote what the client actually said and separate it from what happened in the room. Klarify also generates session context, visual mindmaps of client themes, and reflection prompts for you after each session, so each session gives you more back than the note.
Klarify writes SOAP notes for you, start free
Frequently Asked Questions
What does SOAP stand for in counseling notes?
SOAP stands for Subjective, Objective, Assessment, and Plan. Subjective holds what the client reports, Objective holds what you observe or measure directly, Assessment holds your clinical interpretation, and Plan holds the next steps. The format comes from the problem-oriented medical record developed by Dr. Lawrence Weed in the 1960s (Weed, 1968).
What goes in the Objective section of a therapy SOAP note?
Anything you can observe or measure directly: appearance, behavior, affect, speech, mental status findings, attendance, and scores from measures such as the GAD-7 or PHQ-9. Client statements never go in Objective, even when they sound factual. If you would need the client’s word for it, it belongs in Subjective.
Are SOAP notes psychotherapy notes under HIPAA?
No. SOAP notes are progress notes, part of the official record that clients can access and that can be released with authorization. HIPAA reserves the term psychotherapy notes for a therapist’s separate process notes, kept apart from the rest of the record, and gives that category extra protection (45 CFR 164.501). Keeping the two separate is what preserves the protection.
How long should a SOAP note be?
Long enough that another clinician could continue care from it, and no longer. For most counseling sessions that means a few sentences per section and well under a page. Length is not a compliance signal. Specificity is.
How long do I need to keep SOAP notes?
It depends on where you practice. HIPAA sets no retention period for clinical records; state law and licensing boards do, and the APA recommends keeping full records for seven years after the last service for adults. In Ontario, CRPO requires at least ten years from the last interaction. Check your own board or college before you commit to a schedule.
What is the difference between SOAP and DAP notes?
DAP merges SOAP’s Subjective and Objective sections into a single Data section. That removes the hardest sorting decision in talk therapy, where most of the session is the client’s own report. Choose SOAP when your agency, insurer, or interdisciplinary team expects report and observation separated; choose DAP when nobody is asking for the split.