If you work in mental health, you know it can be challenging to keep your clinical notes consistently structured from one session to the next. That’s why SOAP notes are a go-to method for many professionals. They provide a framework for each session, helping you stay on track so you don’t miss any key points.
Using a SOAP note template can help you include all the essential elements of a SOAP note in a consistent way. Plus, templates can save you time and reduce the stress of trying to remember what needs to be included in each note.
We’ve worked with thousands of mental health practices, and we’ve picked up a few tips on how to effectively take SOAP notes. These tips make note-taking easier by offering clarity on what should be included.
We’ve also created some basic mental health SOAP notes templates below, complete with example notes. Read on to learn more about SOAP notes and how to use these templates effectively.
What Are SOAP Notes in Mental Health Counseling?
The SOAP notes format is widely used for documenting progress notes in mental health. Developed over 50 years ago by an American physician named Larry Weed, SOAP notes break down complex information into manageable sections, making it easier for anyone reviewing the notes to quickly grasp the key aspects of a session.
Despite their widespread use, many programs in higher education don’t offer training on how to effectively use SOAP notes. As a result, mental health professionals often learn how to write these notes on the job, picking up techniques from mentors and colleagues. This informal learning process can lead to variations in how SOAP notes are written. Some may not include enough detail, while others might go overboard, including more information than necessary. In fact, one study showed that average note lengths have increased by more than 60% since 2009. Excessively long notes can lead to information overload and make it difficult for colleagues to find the most pertinent information. That’s why learning how to write your notes well is so important for client care.
Let’s break down what each letter in the SOAP acronym stands for to get a clearer picture:
- S – Subjective: This section captures what the client brings to the session, such as their concerns and the main reasons they’re seeking help. You may want to use direct quotes and all topics that you covered during the session.
- O – Objective: Here, document the facts: diagnoses, signs and symptoms, the client’s mood or affect, and their appearance.
- A – Assessment: This is where you’ll document what you noticed in the session and your interpretation of both objective and subjective information. This may include your impressions of their mood, risk of harm and progress towards goals.
- P – Plan: Finally, the plan outlines the road ahead for the client. It details your approach for future sessions, anticipated frequency and duration of therapy, goals (both short and long-term), and any assignments or tasks you’ve set for the client.
Why are SOAP Notes in Mental Health Counseling Important?
Managing a mental health practice is no small feat. From handling challenging client situations to figuring out where to allocate funds for marketing, it might sometimes feel like you’re constantly putting out fires.
This endless juggling can start to take a toll on the quality of care you provide. While you’re trained to stay present and focused during sessions, it’s understandable if, by the end of a long day, sitting down to write progress notes is the last thing you want to do.
But those progress notes are a critical part of client care. They not only serve as a detailed record of a client’s treatment journey, but they also provide valuable insights for future sessions.
Here are a few reasons why SOAP notes are essential in mental health counseling:
- Documentation of Progress: Progress notes provide evidence that the client is making progress toward their therapeutic goals. This is not only important for the client’s treatment, but also for insurance purposes and proving medical necessity for continued care.
- Communication with Other Professionals: SOAP notes may be shared with other professionals involved in a client’s care, such as physicians or other therapists. These notes provide valuable information about the client’s progress and can help maintain continuity of care.
- Legal and Ethical Compliance: As a mental health professional, you’re held to high standards of legal and ethical compliance. Keeping accurate SOAP notes is not only good practice, but it also demonstrates your commitment to ethical standards.
- Protection in the Event of a Review: In the event of a lawsuit or complaint, your progress notes can serve as evidence of the care provided to the client. Notes also document any potential risks or concerns that may arise during treatment.
- Personal Reflection: Writing progress notes can also serve as a way for therapists to reflect on their own practice and therapeutic approach. It allows you to track your progress in helping the client and make adjustments if necessary.
5 Tips for Writing Better SOAP Notes in Mental Health Counseling
Balancing all the duties of a mental health professional takes a well-defined and efficient approach, and documentation is no exception. If you’re stuck on how best to compile your session notes, we have five essential tips to keep in mind for documentation using the SOAP notes framework:
#1 Timing Is Everything
It helps to identify the optimal moment for note-taking. Writing progress notes during a session might seem efficient at first, but it’s usually more practical to jot down personal notes and write them out into the SOAP format afterward. However, don’t delay too long; aim to complete your notes a few hours post-session. This way, your memory is still fresh, yet you’ve had enough time to process the session’s details.
#2 Keep It Professional and Precise
Your writing style should reflect the professionalism of your role. Avoid casual language, slang and overly complex abbreviations that could obscure the meaning of your notes. Aim for concise and precise language that can be easily understood by anyone else who may need to read your notes. Over 27% of medical malpractice is the result of communication failures, so clear and precise documentation is critical.
#3 Objective and Unbiased Reporting
SOAP notes should be objective and judgment-free, focusing on observable facts and behaviors rather than subjective interpretations without evidence. It helps to remove words like “very” and “a lot” from your note-taking as you’ll be forced to describe the client’s behavior rather than making assumptions about their internal state.
#4 Attention to Detail
Your SOAP notes should always be accurate. Pay close attention to grammatical tense, avoid pronoun confusion and always check spelling. Quotes should be exact and enclosed in quotation marks. Also, be careful with dates, timing of events and spelling of names to avoid potential confusion further down the line.
#5 Correcting Errors Properly
Mistakes are inevitable, but it’s how you address them that counts. Don’t try to hide errors with scratch-outs or correction fluid. Instead, use a strikethrough for incorrect entries, label the mistake clearly by writing ‘error’ next to the correction, and add the correct information alongside your initials. Your corrections should always show the following:
- What was initially recorded;
- The accurate, updated information;
- The identity of the person making the correction (always ensure it’s you correcting your own notes).
SOAP Note Templates for Mental Health with Examples
When writing SOAP notes, it can be helpful to use a template as a guide. Templates provide a structured format and prompts for recording important information in each section.
Anxiety SOAP Note Template with Example Note
Subjective
In this section, record the clients’ concerns in their own words. This may include worries, preoccupations, sleep patterns and how they impact their day-to-day lives.
Example:
Since adopting a cat three months ago, the client reports experiencing frequent, intrusive, thoughts of contracting a viral infection. Soon after the adoption, she saw a news report about the risks of having a cat and has since been worried about becoming ill. She reports washing her hands frequently and having up to four showers per day. She says her hands are dry, cracked, and at times, bleed, due to the harsh soaps she uses.
The client reports she adopted the cat during a stressful time in her life, following the death of her maternal grandmother, whom she was reportedly close with.
She says she “knows” the fear is irrational, but the thoughts won’t go away, and the only way to alleviate the anxiety, momentarily, is to engage in a cleaning ritual.
The client says she works from home, so the behavior does not interfere with her work, but her partner and family have been worried about her. They are also frustrated by her concerns and try to reassure her that it will be okay. She says it is unhelpful when they suggest she rehome the cat as she really loves her cat, but the fear of becoming ill means she does not get to “enjoy” her pet as much as she would like.
She reports experiencing insomnia due to excessive worrying about becoming ill, often staying up late researching symptoms and signs. She gets, on average; four hours of sleep per night.
In retrospect, she says she has always been anxious about hygiene and cleanliness and recalls washing her hands frequently as a child, resulting in dry peeling skin.
Objective
In this section, document the facts: signs, symptoms, and a mental state examination (appearance, behaviors, speech, mood, affect, thoughts, perception, cognition, insight and judgment).
Example:
The client is a 27-year-old woman, dressed in casual clothing.
She rubbed her hands together and picked at her cuticles during the session. Her speech, at times, was pressured, and the content of her worries was related to her cat and health concerns.
The client reports poor sleep and appetite.
The client reports a family history of anxiety: her mother was diagnosed with OCD, and her sister has generalized anxiety disorder. The client has a possible history of OCD symptoms in childhood.
The client denies thoughts of self-harm or suicide.
Assessment
In this section, include your formulation. This involves collating both objective and subjective information to form your impressions of the client’s presentation, and, where applicable, a diagnosis.
Example:
The client’s symptoms are consistent with obsessive-compulsive disorder (OCD). She experiences frequent, unwanted and distressing thoughts about contracting an illness from her cat. The intrusive thoughts are followed by the compulsion to rid herself of germs by excessive hand washing and cleaning. There is marked anxiety present.
She has a possible childhood history of OCD symptoms and a family history of anxiety disorders. This current episode was triggered after two major life events: the death of her maternal grandmother and adopting a cat.
The anxiety impacts her daily functioning, relationships and her health (dry, cracked and bleeding hands).
- Diagnosis: Symptoms suggestive of obsessive-compulsive disorder.
- Differential diagnosis: Possible generalized anxiety disorder or acute grief reaction.
Plan
In this section, include your short-term and long-term goals for therapy.
Example:
- Immediate: Begin cognitive behavioral therapy for OCD. Schedule weekly sessions.
- Follow-Up: Review progress after six sessions.
Depression SOAP Note Template with Example Note
Subjective
In this section, record the clients’ concerns in their own words. This may include their mood, thought processes, motivation levels, sleep patterns and how it impacts their day-to-day lives.
Example:
The client reports feeling “uninterested” in things he’d usually enjoy, such as playing hockey and spending time with his friends. He reports feeling low in mood for six months since his parents separated. It was decided that he would live with his father as his mother works night shifts, but he feels guilty for “leaving” his mother during this difficult time.
The client reports difficulty sleeping and, at times, stays up until 2 am playing video games to “take his mind off things.” He reports having difficulties concentrating at school and not wanting to be around his friends. He blames himself for his parents’ separation. He feels “wound up” and angry much of the time.
Objective
In this section, document the facts: signs, symptoms, and a mental state examination (appearance, behaviors, speech, mood, affect, thoughts, perception, cognition, insight and judgment).
Example:
The client is a fourteen-year-old male who was referred for counseling due to a decline in school performance and withdrawing from his peer friendships.
He was dressed in dark clothing, wearing a hoodie and unlaced shoes.
The clients’ movements were slow and fatigued. His speech was normal in rate and tone.
The client reports a family history of depression: his mother had postnatal depression, and his paternal grandfather was “probably depressed too.” No personal history of depression.
The client denies thoughts of self-harm or suicide but has had occasional thoughts of “wishing I go to sleep and not wake up.”
The client reports disruptions in sleep, loss of appetite, low motivation, difficulties concentrating and mood disturbances (irritability).
Assessment
In this section, include your formulation. This involves collating both objective and subjective information to form your impressions of the client’s presentation, and where applicable, a diagnosis.
Example:
The client’s symptoms are consistent with a major depressive episode and have been present since his parents’ separation six months prior.
He experiences mood disturbances, anhedonia (loss of interest) and self-blame.
The client has occasional passive thoughts of suicide but no plan/ intent.
- Diagnosis: Symptoms suggestive of major depression.
- Differential diagnosis: Possible adjustment disorder or generalized anxiety disorder.
Plan
In this section, include your short-term and long-term goals for therapy.
Example:
- Immediate: Complete suicide risk assessment. Begin interpersonal psychotherapy (IPT) for depression in adolescents. Schedule weekly sessions.
- Follow-Up: Review progress after six sessions.
SOAP Notes – Essential for Mental Health Counseling
We hope you find the above tips and examples useful for creating better SOAP notes. Your documentation is one of the key factors in providing quality mental health services for your clients. With accurate, detailed, and consistently formatted SOAP notes, you can effectively track progress, make treatment decisions, and collaborate with other healthcare professionals involved in your clients’ care.
If you’re looking for a secure and efficient way to record SOAP notes, start a 14-day free trial of Power Diary – no credit card required!
