A SOAP note is a structured clinical document with four sections—Subjective, Objective, Assessment, and Plan—used to capture client-reported concerns, observable findings, the clinician’s impression, and next steps.

What belongs in each SOAP section?

Subjective: client-reported symptoms and quotes. Objective: observable/measurable data (vitals, scales, appearance). Assessment: clinical impression/diagnosis and response to treatment. Plan: interventions, homework, referrals, meds, and follow-up timing.

How detailed should a SOAP note be?

Include enough detail for another provider to understand the case, justify clinical decisions, and support continuity of care—while remaining concise and relevant to the session goals.

What are common SOAP note mistakes?

Mixing subjective and objective data, vague assessments, missing measurable goals in the Plan, excessive jargon, and omitting risk/safety documentation when relevant.

Can SOAP notes be used for insurance or audits?

Yes. Payers and auditors often expect clear linkage from symptoms (S/O) to assessment (A) and a specific, time-bound plan (P). Document medical necessity and measurable goals.

What privacy considerations apply to SOAP notes?

Record only necessary clinical information, avoid unrelated identifiers, follow your jurisdiction’s privacy rules, and store notes in a secure EHR with access controls.

How do SOAP and DAP notes differ?

DAP (Data, Assessment, Plan) combines subjective and objective into one ‘Data’ section. SOAP separates them, which some teams prefer for clarity and handoffs.

Do you have a quick SOAP template example?

S: “Can’t sleep; anxious before presentations.” O: Restless, GAD-7=14. A: GAD—work triggers; partial response to CBT. P: Continue CBT exposure; thought record homework; recheck 1 week.

Any tips to write SOAP notes faster?

Use a reusable template, smart phrases, checklists for Objective findings, and bullet points in Assessment/Plan. Document immediately after sessions when details are fresh.

SOAP note template

SOAP Template: Consistent Clinical Documentation Guide

Master SOAP notes with a ready-to-use template. Learn what to put in Subjective, Objective, Assessment, and Plan—plus pro tips to write faster, clearer, audit-ready documentation.

John Constantine

12 Oct 2025 • 2 min read

SOAP notes are a widely used method for documenting client interactions in healthcare, therapy, and counseling. The SOAP format—standing for Subjective, Objective, Assessment, and Plan—provides a structured approach to recording essential information, improving communication among providers, and supporting continuity of care.

Whether you’re a therapist, counselor, or healthcare professional, using a SOAP note template can save time, improve consistency, and ensure your documentation meets professional standards.

Why Use a SOAP Note Template?

A SOAP note template offers several key benefits:

Efficiency: No need to start from scratch for each client or session.

Consistency: Ensures all important information is captured in a uniform way.

Professionalism: Makes your notes easier to read and share with colleagues or insurance providers.

Compliance: Helps meet documentation standards required in healthcare and mental health settings.

What Does SOAP Stand For?

Each section of a SOAP note serves a distinct purpose:

Subjective (S): The client’s own words, feelings, symptoms, or concerns. This section captures their perspective and may include direct quotes.

Objective (O): Observable facts, measurements, and clinical findings. This is where you record what you see, hear, or measure during the session.

Assessment (A): Your professional analysis or diagnosis, synthesizing the information from the first two sections.

Plan (P): The next steps for treatment, including interventions, homework, referrals, or follow-up appointments.

How to Write Each Section of a SOAP Note

Subjective:
Record the client’s self-reported symptoms, feelings, or goals. Use their own words when possible.
Example: “I’ve been feeling anxious and can’t sleep at night.”

Objective:
Document measurable or observable facts. This could include appearance, behavior, test scores, or your observations as a provider.
Example: Client appeared restless, avoided eye contact, and scored 14 on GAD-7 (moderate anxiety).

Assessment:
Provide your clinical impression or diagnosis. Summarize the session based on the subjective and objective information.
Example: Symptoms consistent with generalized anxiety disorder. Anxiety appears to be triggered by work-related stress.

Plan:
Outline what happens next. Be specific about interventions, homework, referrals, or future appointments.
Example:

Continue with cognitive behavioral therapy techniques.
Assign thought record homework.
Next session scheduled for one week.

Ready-to-Use SOAP Note Template

Copy and use the template below for your own documentation needs:

SOAP Note Template

Client Name:
Date:
Session Number:
Provider:

S – Subjective
[Record the client’s self-reported symptoms, concerns, feelings, or goals. Use direct quotes when possible.]

O – Objective
[Document observable, measurable facts. This may include appearance, behavior, test results, or therapist’s observations.]

A – Assessment
[Provide your clinical impression, diagnosis, or summary of the session based on the subjective and objective information.]

P – Plan
[Outline next steps for treatment, interventions, homework, referrals, or follow-up plans. Be specific and actionable.]

Tips for Effective SOAP Notes

Be clear and concise.

Use bullet points for clarity, especially in Objective and Plan sections.

Avoid jargon unless necessary; explain any medical terms.

Review and edit your notes for completeness and accuracy.

Conclusion

A SOAP note template is a simple but powerful tool for improving your clinical documentation. By following this structured approach, you’ll ensure your notes are thorough, professional, and easy to reference—saving you time and supporting better client care.