Progress Note Template: SOAP Format Guide

Every therapist knows the feeling: a full day of emotionally demanding sessions, and now you have to document each one before the details fade. Progress notes are not just paperwork - they are your clinical memory, legal protection, and the roadmap for client care. The SOAP format has remained the gold standard for decades because it works. This comprehensive guide will help you master SOAP notes, compare them to alternatives, and dramatically reduce your documentation time.

2-4 hrs

Daily documentation time for average therapist

78%

Therapists cite notes as top burnout factor

24 hrs

Recommended completion window

15 min

Ideal time per SOAP note

What Is the SOAP Note Format?

SOAP stands for Subjective, Objective, Assessment, and Plan. Developed in the 1960s by Dr. Lawrence Weed at the University of Vermont, this structured format was originally designed for medical records but quickly became the preferred method for mental health documentation. The genius of SOAP lies in its logical flow: it mirrors how clinicians actually think about client sessions.

Unlike free-form narrative notes, SOAP provides a consistent framework that makes it easier to track progress over time, communicate with other providers, and demonstrate medical necessity for insurance purposes. Whether you work in a group practice, community mental health center, or private practice, SOAP notes create a shared language that everyone understands.

Why SOAP Remains the Gold Standard

Insurance companies, accreditation bodies, and courts recognize SOAP as a professionally accepted documentation method. When your notes follow this format, you are speaking the language that auditors, supervisors, and legal professionals expect to see. This is not about rigid compliance - it is about protecting yourself and serving your clients better.

Breaking Down Each SOAP Section

Each letter in SOAP represents a distinct type of clinical information. Understanding what belongs in each section eliminates confusion and speeds up your documentation process.

S - Subjective: The Client's Perspective

This section captures what the client tells you - their words, feelings, and experiences. Think of it as the client's voice in your documentation.

Chief complaint or presenting concern for this session
Direct quotes that illustrate key themes
Self-reported symptoms, mood, and functioning
Progress on homework or between-session goals
Relevant life events since last session

O - Objective: Your Clinical Observations

Document what you directly observe - the facts that any trained clinician would notice. This section grounds your assessment in observable data.

Appearance, grooming, and hygiene
Affect, mood presentation, and congruence
Speech patterns, thought process, and content
Behavioral observations during session
Assessment scores or measurement tools administered

A - Assessment: Your Clinical Judgment

Here is where your expertise shines. Synthesize the subjective and objective data into clinical meaning. This is what you are trained to do.

Progress toward treatment goals (improving, stable, declining)
Diagnostic impressions and any changes
Risk assessment (suicidal ideation, self-harm, harm to others)
Effectiveness of current interventions
Barriers to treatment and client strengths

P - Plan: Next Steps and Action Items

Document what comes next - for both you and the client. This section creates accountability and continuity of care.

Interventions to continue or modify
Homework or between-session assignments
Referrals or coordination with other providers
Next session date and frequency
Crisis plan reminders if applicable

SOAP vs. DAP vs. BIRP: Choosing the Right Format

While SOAP is the most widely used format, you may encounter DAP and BIRP notes in certain settings. Understanding the differences helps you adapt to various workplace requirements or choose the best fit for your practice style.

SOAP Format

Best for: Medical settings, insurance billing, interdisciplinary teams

S - Subjective (client report)
O - Objective (observations)
A - Assessment (clinical judgment)
P - Plan (next steps)

Separates client data from clinician observations

DAP Format

Best for: Counseling centers, private practice, faster documentation

D - Data (combines S and O)
A - Assessment (clinical judgment)
P - Plan (next steps)

Faster to write with fewer sections

BIRP Format

Best for: Behavioral health, substance abuse treatment, outcomes tracking

B - Behavior (what happened)
I - Intervention (what you did)
R - Response (client reaction)
P - Plan (next steps)

Emphasizes interventions and outcomes

Which Should You Choose?

Consider these factors when selecting your format:

Employer or agency requirements
Insurance and billing needs
State licensing board preferences
Personal documentation style

When in doubt, SOAP is the safest choice

Complete SOAP Note Example

Seeing a complete example helps you understand how the sections flow together. Here is a sample SOAP note for a client with generalized anxiety disorder, demonstrating appropriate detail and clinical language.

Sample Progress Note - Individual Therapy Session

Session 8 of 16 - Generalized Anxiety Disorder (F41.1)

Subjective

Client reports "feeling more in control this week" after practicing breathing exercises daily. States anxiety peaked on Tuesday during a work presentation but was able to use grounding techniques learned in session. Describes sleep as "better but not great" with falling asleep taking 30 minutes versus previous 60+ minutes. Client completed thought record homework, identifying three cognitive distortions related to perfectionism. Reports motivation to continue treatment and try exposure exercise discussed last session.

Objective

Client arrived on time, casually dressed with appropriate hygiene. Affect was brighter than previous sessions, with occasional smiling. Speech was normal rate and volume. Thought process was logical and goal-directed. No evidence of suicidal or homicidal ideation. GAD-7 score of 11 (moderate), decreased from 15 at intake. Client demonstrated correct diaphragmatic breathing technique. Eye contact was appropriate throughout session.

Assessment

Client is making good progress toward treatment goals. GAD-7 reduction of 4 points indicates meaningful symptom improvement. Cognitive restructuring skills are developing - client independently identified perfectionism pattern. Sleep hygiene improvements suggest decreased physiological hyperarousal. Client demonstrates strong engagement with treatment and homework compliance. Risk level remains low. Prognosis is good given current trajectory and client motivation.

Plan

1) Continue weekly individual therapy using CBT framework. 2) Introduce graduated exposure hierarchy for work presentation anxiety next session. 3) Client to continue daily breathing practice and thought records. 4) Assign behavioral experiment: volunteer for small team meeting update. 5) Re-administer GAD-7 in two sessions to track progress. 6) Next session scheduled for Thursday at 2:00 PM.

Common SOAP Note Mistakes to Avoid

Even experienced clinicians make documentation errors that can create problems during audits or legal proceedings. Here are the pitfalls to watch for and how to avoid them.

Avoid These Errors

Copy-pasting notes between sessions
Using vague language like "client did well"
Waiting days to complete documentation
Putting opinions in Objective section
Omitting risk assessment documentation

Do This Instead

Write unique content for each session
Use specific, measurable descriptions
Complete notes within 24 hours
Keep observations factual and verifiable
Document risk status in every note

The 24-Hour Rule

Memory fades quickly - studies show we forget up to 50% of session details within 24 hours. Complete your notes the same day whenever possible. If you cannot finish immediately, jot down key quotes and observations before your next client. Your future self (and your auditors) will thank you.

Writing SOAP Notes Faster Without Sacrificing Quality

Documentation should not consume your evenings and weekends. Here are practical strategies that experienced therapists use to write thorough notes in less time.

10 Time-Saving Strategies

1
Use templates with standard phrases
Create a library of clinically appropriate phrases for common observations. Customize templates for different session types.
2
Take brief notes during sessions
Jot down key quotes and observations in real-time. Review with clients to ensure accuracy.
3
Block documentation time
Schedule 10-15 minutes between sessions specifically for notes. Treat this as non-negotiable clinical time.
4
Use voice dictation
Speaking is faster than typing for most people. Modern dictation software handles clinical terminology well.
5
Keep assessment scales handy
Standardized measures provide objective data and save you from writing lengthy descriptions.

How TheraFocus Streamlines SOAP Documentation

TheraFocus was built by therapists who understand the documentation burden. Our platform includes purpose-built tools that reduce note-writing time by up to 60% while improving clinical quality.

With built-in SOAP templates, you simply fill in session-specific details while the structure handles itself. The platform prompts you for each section, ensures you do not miss critical elements like risk assessment, and auto-populates client information and session metadata. For therapists who prefer other formats, DAP and BIRP templates are also available.

AI-Assisted Documentation

Our optional AI writing assistant can suggest clinical language, help you articulate observations, and ensure your notes meet insurance and audit requirements. You stay in control - the AI assists, you approve. Every note remains authentically yours while taking a fraction of the time to write.

Frequently Asked Questions

How long should a SOAP note be?

A well-written SOAP note typically ranges from 200-400 words, though this varies by setting and payer requirements. The goal is thoroughness without redundancy. Each section should contain enough detail to paint a clear clinical picture, but avoid padding. If an auditor or supervisor could understand the session from your note alone, you have written enough.

Do I need to include a risk assessment in every note?

Yes. Documenting risk status in every session note is a clinical and legal best practice. Even when clients present as low-risk, explicitly stating this protects you and demonstrates ongoing clinical vigilance. A simple statement like "No suicidal ideation, homicidal ideation, or self-harm urges reported or observed. Risk level: low" takes seconds to write and can be crucial if questions arise later.

Can I use abbreviations in SOAP notes?

Use only standardized, widely recognized abbreviations. "SI" for suicidal ideation, "GAD" for generalized anxiety disorder, and "CBT" for cognitive behavioral therapy are generally acceptable. Avoid creating your own shorthand or using abbreviations that could be misinterpreted. When in doubt, write it out. Your notes may be read by other providers, attorneys, or auditors who need to understand them clearly.

What is the difference between progress notes and psychotherapy notes?

Progress notes (like SOAP notes) are part of the official medical record and document treatment provided. They must be shared with insurance companies and can be subpoenaed. Psychotherapy notes (sometimes called process notes) are the therapist's private notes containing impressions, hypotheses, and details of therapeutic conversation. Under HIPAA, psychotherapy notes receive extra protection and generally cannot be released without specific patient authorization. Most therapists maintain both types of documentation.

How do I document when a client misses or cancels a session?

Document missed and canceled sessions with a brief note including: the scheduled date and time, whether the client canceled in advance or no-showed, any reason given, your attempts to reach the client (if applicable), and next steps. This creates a record of attendance patterns that may be clinically relevant and protects you regarding billing and continuity of care.

Should I let clients read their progress notes?

Under HIPAA and the 21st Century Cures Act, clients generally have the right to access their medical records, including progress notes. Many therapists now practice "open notes" and find it strengthens the therapeutic relationship. If you write notes with the assumption that clients may read them, you will naturally use respectful language and avoid clinical jargon that could be misunderstood. Some EHR systems even allow clients to view notes through a patient portal.

Key Takeaways

SOAP format provides a logical structure that mirrors clinical thinking: what the client said, what you observed, what it means, and what happens next
Complete notes within 24 hours while session details are fresh - your documentation quality depends on it
Always include risk assessment documentation, even when clients present as low-risk
Use templates and standardized phrases to save time without sacrificing quality or personalization
TheraFocus provides built-in SOAP templates with AI assistance to help you document faster while meeting all clinical and compliance standards

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