How to write soap notes for counseling

While documenting progress notes is an important aspect of being a behavioral healthcare professional, it’s not usually part of the curriculum to prepare you in your career. Luckily, we’ve got you covered on this one – let’s review what SOAP notes are and how to write them.

SOAP notes are intended to capture specific information about a client and certain aspects of the session. SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning). All SOAP notes should be kept in a client’s medical record.

Let’s breakdown the contents of SOAP notes so you can document your clients’ sessions appropriately:

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(S)Subjective - 

Statement about relevant client behavior or status.

• This is where you as the clinician enter information regarding the client’s chief complaint, presenting problem, and any other relevant information including direct quotes from the client.  You might also include personal or medical issues that may impact or influence the client’s day-to-day routine.
• Contains a complete account of the client’s description of symptoms
• Progress from the last encounter

Content to include:

• Jon states: “I didn’t sleep well last night and I’ve felt irritable all day”.  We discussed his sleeping patterns and current stressors as possible reasons for his lack of sleep.
• Jon reports bouts of depressive episodes and crying spells in the past week & says “I just start crying out of nowhere.  I don’t know where it’s coming from”.  During last week’s session, I remember Jon mentioning the anniversary of his mother’s death; we talked about this being a possible trigger for his current emotional state. 

Content to avoid: 

• Do not include statements without supporting facts; statements such as “Client was willing to participate” is an opinion until you provide facts to support this observation. Consider only information that you feel is relevant and statements from the client, loved ones, or teachers that can be attributed to your client’s mood, motivation, awareness, and willingness to participate. 
• When making subjective statements, include pertinent evidence. For example: “Client appears nervous as evidenced by fidgeting of hands, not maintaining eye-contact, and shortness of breath during our session”.

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(O)Objective - 

Observable, quantifiable, and measurable data.

• This part of the note includes factual documentation about the client including a client’s diagnosis, behavioral and/or physical symptoms, appearance, orientation, and mood/affect.  
• How the client presented themselves (affect, behavior, eye-contact, nervousness, talkativeness) based on your observations
• Verbal/non-verbal
• Body posture
• Affect when discussing certain topics or issues

Content to include:

• Physical, interpersonal, and psychological observations
• General appearance
• Affect & behavior 
• Nature of therapeutic relationship
• Client’s strengths
• Client’s mental status
• Client’s ability to participate in the session
• Client’s responses to the process
• Written materials such as reports from other providers, psychological tests, or medical records can be included here (if applicable) 

Examples:  

• Jon is alert: oriented to time and place & he’s actively participating during today’s session as indicated by positive responses and prompt replies.
• Jon displays a mostly flat/blunted affect, hygiene is below baseline.  He takes several seconds to respond to questions I ask him during the session.  

Content to avoid:

• General statements without supporting data 
• Avoid assumptive statements pertaining to behavior
• Labels
• Personal judgments
• Value-laden language
• Opinionated statements (personal rather than professional opinions)
• Words/phrases that have negative connotations and/or are open to personal interpretations (ex: uncooperative, obnoxious, normal, drunk, spoiled)

Example:  

• “Jon arrived drunk and was acting rude & obnoxious during today’s session.”

(A)Assessment- 

Assimilate S. and O. section.

• Use professionally acquired knowledge to interpret the information given by the client during the session.  

• Implement clinical knowledge and understanding (DSM/Therapeutic Model, identify themes or patterns) 
• Update/include DSM criteria observations exhibited by the client

Content to include:

• Client appeared unusually disheveled, exhibited excessive anxiety and worry toward partner’s threat of abandonment and denial of autonomy.  Client presented an abundance of guilt and shame due to infidelity from their partner. Provider feels this may contribute to the immoderate emotional response and intemperate consumption of alcohol client is currently experiencing.
• Client appears to continue experiencing anxiety
• Client continues to experience family-related stressors
• Client exhibited signs of moderate depression
• Client anxiety has increased in severity and appears to meet the criteria for GAD

Content to avoid: 

• Repeating your previous statements in the S. O. sections. In this section, you should instead include: progress, regression, or plateau of client progress. 

(P) Planning- (Plans for client) 

Outline the next course of action as far as the treatment plan goes, given the preceding 

information gathered during your session.

• Focus on your next steps for the upcoming session.  Stay aligned with your overall treatment plan without reinstating it in full in this section.
• Focus on things both parties have agreed to 
• Note nutritional, physical, medical attributes that will contribute to the client’s therapeutic goals
• Note any progression/regression client has made in treatment
• Implementation
• Should be aligned with assessment and direct

Examples of content to include: 

• Provider will introduce designated assessments to assess the client’s focus and uncontrollability.
• Focus on client’s reported symptoms or issues in daily functioning (frequency, duration, intensity, and type), if applicable.
• Provider will continue to build trust and confidence with client to allow space for exploration of previous events similar to current stressors, and explore those conclusions.
• “Client will consult with a licensed nutritionist, in order to create a healthy diet and lifestyle plan.”
• “Client will begin yoga classes at the local gym.”
• “Client is committed to attending group therapy sessions for eating disorders.”

Content to avoid: 

• Restating overall treatment plan (as opposed to goals for the next session)
• Unrealistic, immeasurable goals to be accomplished before the client’s next session.

Tips for completing SOAP notes:

• Consider how the patient is represented: avoid using words like “good” or “bad” or any other words that suggest moral judgments
• Avoid using tentative language such as “may” or “seems” 
• Avoid using absolutes such as “always” and “never”
• Write legibly 
• Use language common to the field of mental health and family therapy 
• Use language that is culturally sensitive 
• Use correct spelling/grammar
• Proofread your notes
• Write your note as if you were going to have to defend its contents.
• Use clear and concise language. Avoid using slang, poor grammar or odd abbreviations.
• When quoting a client, be sure to place the exact words in quotation marks.
• Keep your notes short and to-the-point. Be clear and complete. Avoid expanding beyond what is required for each section.

And remember:  there is no such thing as the perfect progress note!

Documentation Requirements Specific to Video Telehealth

Progress notes are also required for video telehealth sessions. Below are the required components to include in those notes.

• date of service
• start and stop time
• the date of the next session
• the interventions
• mental status
• A statement that the service was provided using video telehealth or telephone. Example: “Met with client via video conference.”
• location of the provider: home vs. office
• The provider should be conducting therapy from the office address that’s on file with the insurance company 

If conducting a family session, document who is present. Example: “Rita and her mother are present for this session.”

How do doctors or therapists track what is happening with a patient or client from one visit to the next?

How do these professionals communicate this information with other professionals also working with the patient or client?

Years ago, this type of communication was not easy. It often meant that a client had to remember from visit to visit what they said to one doctor and then to another.

Now, medical professionals use SOAP notes for this purpose. This type of note-taking system offers one clear advantage: consistent, clear information about each patient during each visit to a provider. When the providers are part of the same group, this information can be easily shared.

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What Are SOAP Notes?

Professionals in the medical and psychological fields often use SOAP notes while working with patients or clients. They are an easy-to-understand process of capturing the critical points during an interaction. Coaches also can make use of SOAP notes, with some adaptations.

SOAP notes are structured and ordered so that only vital and pertinent information is included. Initially developed by Larry Weed 50 years ago, these notes provide a “framework for evaluating information [and a] cognitive framework for clinical reasoning” (Gossman, Lew, & Ghassemzadeh, 2020).

SOAP notes are primarily the realm of medical professionals; however, as you continue reading, you will see examples of how you might adapt them for use in a coaching session.

To begin, the acronym SOAP stands for the following components:

Subjective

During the first part of the interaction, the client or patient explains their chief complaint (CC). There might be more than one, so it is the professional’s role to listen and ask clarifying questions. These questions help to write the subjective and objective portions of the notes accurately.

The descriptor ‘subjective’ comes from the client’s perspective regarding their experiences and feelings. It might also include the view of others who are close to the client.

An example of a subjective note could be, “Client has headaches. Client expressed concern about inability to stay focused and achieve goals.”

Another useful acronym for capturing subjective information is OLDCARTS (Gossman et al., 2020).

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
• Alleviating and aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least severe, 10 being the most severe, how does the patient rate the CC?

Think back to when you have had an appointment with a doctor. How many of these questions did your doctor ask? Chances are, they asked all of them. These questions are part of the initial intake of information and help the doctor or therapist assess, diagnose, and create a treatment plan.

A coach can easily adapt this method to their sessions and exclude whatever does not apply.

For example, a life coach may not need to know or ask about location unless the client indicates that every time they are in a particular spot, they notice X. Here, the idea is shifted from a location in the body to a location in the environment.

Objective

The professional only includes information that is tangible in this section. In a clinical setting, this might be details about:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians

Some clinical examples include, “Patients heart rate is X.” “Upon examination of the patient’s eyes, it was found that they are unable to read lines X and X.”

In a coaching situation, a coach might include some of this information, but it depends on why the client is seeking assistance from the coach and the type of coaching. For instance, a health or fitness coach might want to note diagnostic details like vital signs before, during, and after exercise.

Most coaches do not talk in terms of symptoms or signs, but if you happen to do so, then it is important to understand the distinction between them.

Symptoms are what the person tells you is going on physically, psychologically, and emotionally. They are the client’s subjective opinion and should be included in the “S” part of your notes.

Signs are objective information related to the symptoms the client expressed and are included in the “O” section of your notes.

Using the example from earlier, a coach might determine that the “S” is the client expressing concern over an inability to complete tasks and achieve a larger goal. The “O” is their observation that the client has no time-keeping devices.

After further discussion, the coach may discover that the client does not plan their day with any structured tool. They use sticky notes as reminders. Each of these small details might relate to the CC: an inability to stay focused and complete goals.

On the other hand, a medical doctor would assess the headache issue and test the person’s eyesight, especially if the patient does not already wear glasses.

The doctor might also explore whether the patient has attention deficit-hyperactivity disorder because the CC mentions “an inability to focus and achieve goals.”

Assessment

In this section, the professional combines what they know from both the subjective and objective information. Here, the therapist or doctor identifies the primary problem, along with any contributing factors.

They also analyze the interaction between problems, as well as any changes. When finished, the clinician has a diagnosis of the problem, a differential diagnosis (other possible explanations), discussion, and a plan.

Coaches do not “diagnose” in the traditional sense. Their role is generally one of assisting a client in seeing what they typically already know, but with greater clarity and, perhaps, renewed purpose.

Plan

A plan is where the rubber meets the road. Working with the client or patient, the clinician creates a plan going forward. The plan might include additional testing, medications, and the implementation of various activities (e.g., counseling, therapy, dietary and exercise changes, meditation.)

In a coaching relationship, the coach works with the client to create realistic goals, including incremental steps. This plan includes check-in points and deadlines for each smaller goal and the larger one. The coach might assign homework just as a therapist would. Often the homework offers opportunities for self-reflection. It also provides practice and acquisition of a new skill.

There are other considerations and inclusions used in the medical field. Gossman et al. (2020) also point out several limitations regarding the use of SOAP notes, including:

• The order places the less essential details at the top. It forces the clinician to lose time scanning for necessary information during subsequent visits.
• There is no section addressing how conditions change over time.
• There also is no assessment area for how the plan is working.

Why Are SOAP Notes Important?

Cynthia Moreno Tuohy, executive director of the Association for Addiction Professionals, has highlighted the importance of quality SOAP notes for more than 40 years.

At the 2016 NCRG Conference on Gambling and Addiction, she covered SOAP notes and the elements of good documentation.

According to Tuohy (2016), good documentation includes:

• Use of direct quotes from the patient or client
• A distinction between facts, observations, hard data, and opinions
• Information written in present tense, as appropriate
• Internal consistency
• Relevant information with appropriate details
• Notes that are organized, concise, and reflect the application of professional knowledge

SOAP notes offer concrete, clear language and avoid the use of professional jargon. They include descriptions using the five senses, as appropriate. They also avoid value-heavy terms. Impressions made by the clinician are labeled as such and based on observable data. Written documentation is about gathering the facts, not evaluating them.

Documentation protects the medical and therapeutic professionals while also helping the client. Clear notes communicate all necessary information about the patient or client to all of the people involved in the person’s care. SOAP notes facilitate the coordination and continuity of care.

Writing Your SOAP Notes

The primary thing to keep in mind is that SOAP notes are meant to be detailed, but not lengthy. They are a clear and concise record of each interaction with the patient or client.

Following the format is essential, but it is possible to reorder it so that the assessment and plan appear at the top (APSO). Doing this makes it much easier to locate the information you might need during future meetings or appointments.

The following video by Jessica Nishikawa provides additional information regarding why SOAP notes are used, by whom, and how.

2 SOAP Note Examples

Your client Tom Peters met with you this morning. Your notes are as follows:

S: “They don’t appreciate how hard I’m working.”
O: Client did not sit down when he entered. Client is pacing with his hands clenched. Client sat and is fidgeting. Client is crumpling a sheet of paper.
A: Needs ideas for better communicating with their boss; Needs ideas for stress management.
P: Practice conflict resolution scenarios; Practice body scan technique; Go for a walk during lunch every day for one week.

Your client Rosy Storme met with you this afternoon.

S: “I’m tired of being overlooked for promotions. I just don’t know how to make them see what I can do.”
O: Client is sitting in a chair, slumped forward, and burying her face in her hands.
A: Needs ideas for better communicating her ideas with her boss; Needs ideas for how to ask for more responsibility; Needs ideas for tracking her contributions.
P: Practice asking for what you want scenarios; Volunteer for roles within the company that are unrelated to current job; Brainstorm solutions to problems employer faces.

3 Useful Templates

Numerous websites offer free SOAP templates. Most are designed for use in the medical professions, including client-centered therapy and counseling. Here are three templates you can use for a medical visit, therapy, or coaching session.

1. SOAP note for medical practitioners (Care Cloud, n.d.):

2. SOAP note for counseling sessions (PDF)

3. SOAP note for coaching sessions (PDF)

A Take-Home Message

Whether you are in the medical, therapy, counseling, or coaching profession, SOAP notes are an excellent way to document interactions with patients or clients. SOAP notes are easy to use and designed to communicate the most relevant information about the individual. They can also provide documentation of progress.

For clinical professionals, SOAP notes offer a clear, concise picture of where the client is at the time of each session. They contribute to the continuity of care and are a tool for risk management and malpractice protection. For the client, they provide documentation of their problem, diagnosis, treatment options, and plans.

What is your experience using SOAP notes? How have you applied them to your coaching practice?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.

References

• Care Cloud (n.d.) Free SOAP note template. Retrieved March 6, 2020, from https://www.carecloud.com/continuum/free-soap-note-template/
• Gossman, W., Lew, V, & Ghassemzadeh, S. (2020, September 3). SOAP notes. StatPearls Publishing. Retrieved March 6, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK482263/
• Nishikawa, J. (2015, October 17). SOAP notes [Video]. YouTube. https://youtu.be/9TZqTtbBVXc
• Tuohy, C. M. (2016, September 25–26). Foundations of addiction treatment [Conference session]. 17th Annual NCRG Conference on Gambling and Addiction, Las Vegas, NV.