Writing comprehensive SOAP notes can be consuming for mental health professionals, especially when balancing a full caseload of clients.
The pressure to maintain detailed, professional documentation while staying HIPAA-compliant often leads to after-hours work and documentation anxiety.
Effective SOAP documentation forms the foundation of quality client care and accountable record-keeping. These structured notes serve as both a legal record of your sessions and a valuable utility for tracking client progress.
In counseling and therapy settings, SOAP notes also instruct treatment decisions and facilitate consistent communication across healthcare providers.
Here, we dive into the art of SOAP note taking for counseling dynamics and share insightful examples to help refine your notes. First, let’s cover some basics.
Understanding SOAP Notes Structure
Properly Documenting complex therapy sessions can feel daunting. But SOAP notes don’t have to be your end-of-day nightmare.
When done right, writing good SOAP notes is one of the most powerful tools in your clinical toolkit, helping you track progress and maintain high-quality care without losing your evenings to paperwork.
Think of SOAP notes as telling your client’s story in four clear parts. Here’s how each section works in real-world practice:
Subjective (S) - The Client’s Voice
The first set of notes captures what your client brings to the session - their experiences, struggles, and wins. No need to dress it up in clinical language. Simply document what they’re sharing about their journey, like:
- Direct quotes from the client about their emotional state
- Recent life events or stressors
- Progress or setbacks since the last session
- Current symptoms or concerns
Objective (O) - What You See
While your client talks, you pick up on all those essential behavioral cues and patterns. The “O” is all about your professional observations - the things happening in a session that your client might not even notice, such as:
- Client’s appearance and behavior during the session
- Non-verbal cues and body language
- Level of engagement in therapy
- Mood and affect presentation
Assessment (A) - Your Clinical Insight
This section transforms raw observations into clinical understanding. Here’s where you synthesize information to support diagnostic decisions, evaluate progress, and identify treatment priorities.
- Primary diagnosis and differential diagnostic considerations
- Changes in symptom presentation and functional status
- Progress evaluation: Movement toward or away from treatment goals
- Risk assessment findings and safety considerations
- Identification of maintaining factors and barriers to progress
- Response to current interventions or treatment modalities
Plan (P) - Next Steps
Keep it concrete and actionable. What exactly needs to happen before the next session? What are you and your client working toward? Make sure anyone reading this note knows exactly where treatment is headed.
- Specific interventions used or planned
- Homework assignments
- Referrals or consultations needed
- Scheduling of next session
- Adjustments to treatment goals
4 Examples of SOAP Notes in Mental Health Counseling
Let’s explore real-world examples of SOAP notes across varying mental health scenarios, capturing essential clinical information, client progress, and a plan of action while maintaining professional clarity and HIPAA compliance. At the very least, these SOAP note samples may expand your note-taking vocabulary.
1. Scenario: Work-Related Anxiety
A 45-year-old newly promoted senior manager seeks counseling after experiencing increasing anxiety about their new leadership role, particularly during executive meetings and team management responsibilities.
SOAP Note Example:
S: Client reports “feeling like an imposter” in meetings. Says “I rehearse every interaction in my head for hours” and expresses difficulty delegating tasks. Reports working late to “double-check everything” and experiencing Sunday night panic attacks before work week begins.
O: Presents with professional demeanor but displays nervous energy through frequent position shifts in chair. Speech is precise and measured, suggesting careful self-monitoring. Maintains strong eye contact but shows visible tension in shoulders and jaw area.
A: Symptoms consistent with situational anxiety triggered by recent promotion. Client demonstrates high insight into perfectionist tendencies but shows maladaptive coping through overwork and excessive preparation. No current safety concerns noted.
P:
- Introduced mindfulness-based stress reduction techniques
- Assigned behavioral experiment: Delegating one task per day
- Developed hierarchy of anxiety-producing leadership scenarios
- Created morning routine to replace pre-work rumination
- Schedule next session for same time next week
2. Scenario: Major Depressive Episode
A 36-year-old software developer seeks counseling after a three-month period of declining mood, work performance issues, and increasing social isolation following a relationship breakdown.
SOAP Note Example:
S: Client reports “going through the motions” at work and home. Describes sleeping 10-12 hours daily yet feeling exhausted. Reports working remotely with camera off due to lack of self-care. Acknowledges passive suicidal ideation but denies plan or intent, stating he would never do that to his sister.
O: Arrived in wrinkled clothes and appeared unbathed. Diminished psychomotor skills evident in slowed speech and movements. Demonstrated flat affect with occasional appropriate emotional response when discussing sister. Cognitive processing slowed but intact.
A: Symptoms consistent with major depressive episode, moderate severity. Client maintains protective factors through family connection and employment. Current functioning significantly impaired but demonstrates capacity for insight. Risk assessment indicates low immediate safety concern with strong protective factors.
P:
- Implement basic behavioral activation starting with daily shower and one home-cooked meal
- Begin mood tracking using phone app
- Discuss psychiatric consultation for medication evaluation
- Maintain twice-weekly sessions temporarily
- Schedule next appointment for Thursday at 2 PM
- Planned check-in call for Monday morning
3. Scenario: Grief and Life Transition
A 58-year-old retired teacher seeks counseling three months after losing her spouse of 30 years. She reports struggling with both grief and adapting to living alone for the first time.
SOAP Note Example:
S: Client reports “the house feels emptier each day.” Describes establishing new routines as “overwhelming” and admits to avoiding social interactions. States “I keep expecting to hear his key in the door” and reports difficulty sleeping in their shared bedroom. Acknowledges small improvement in ability to discuss spouse without immediate tearfulness.
O: Arrived on time, well-groomed but appearing fatigued. Affect more animated when discussing memories of spouse, with appropriate emotional expression. Shows signs of isolation but maintains awareness of the need for connection. Tearful at times but able to self-regulate.
A: Client experiencing normal grief response complicated by challenges of identity reformation. Shows increasing ability to integrate loss while struggling with practical aspects of independent living. Demonstrates good insight and no signs of complicated grief at this time.
P:
- Continued validation of grief process while exploring new daily structures
- Identified one small daily task to accomplish independently
- Discussed joining local widow/widower support group
- Created sleep hygiene plan for bedroom adjustment
- Schedule next session in one week
4. Scenario: Academic and Social Anxiety
A college freshman seeks counseling during their second semester, reporting increasing isolation and academic struggles after transitioning to university life.
SOAP Note Example:
S: Client says they “hit a wall” with coursework and feeling “invisible” on campus. Describes spending most weekends alone in her dorm room and missing three classes last week. States “I can’t focus like I used to” and “everyone else seems to have it figured out.” Mentions increasing physical symptoms, including headaches and upset stomach before classes.
O: Arrived 10 minutes late, wearing casual attire. Speaks softly with downcast eyes, but becomes more engaged when discussing previous academic achievements. Displays subtle signs of agitation when talking about social situations, including foot tapping and sleeve-pulling. Phone notifications caused visible tension during the session.
A: Presenting symptoms suggest adjustment disorder with mixed anxiety and depressed mood. Academic performance anxiety appears to be exacerbating social withdrawal. Shows insight into changes from high school success but struggles to implement new coping strategies in college.
P: For the coming week, client will practice progressive exposure to social settings by studying in the library rather than dorm room. We agreed to coordinate with campus academic support services for study skills coaching. Client will track anxiety symptoms using a mood app and implement one daily social interaction, no matter how brief. Next session scheduled for Tuesday at 3 PM.
Common Note-Taking Challenges
The clock strikes 6 PM, and you’re still taking notes from your morning sessions. If this scenario hits close to home, you’re not alone. Let’s talk about the real challenges that make documentation feel like climbing a mountain - and more importantly, how to tackle them.
Time Management
Finding time to write detailed SOAP notes between back-to-back sessions can feel impossible. Many therapists find themselves choosing between taking a much-needed break or catching up on documentation. The pressure to complete notes while memories are fresh often conflicts with the need to prepare for the next client.
Related Read: Productivity hacks for therapists
Quality vs. Quantity
Striking the right balance between comprehensive documentation and concise notes is a constant challenge. You need enough detail to track progress and meet insurance requirements, but too much information can obscure the important points and make future review difficult.
Maintaining Objectivity
Writing clear, objective observations while steering away from subjective interpretations requires mindful attention. Documenting specific behaviors and direct quotes rather than personal opinions or unsupported conclusions is essential. This becomes incredibly challenging when working with complex cases or emotionally charged sessions.
HIPAA Compliance
The need to maintain detailed records while protecting client privacy is a delicate balance. It’s critical to include sufficient clinical information while ensuring your documentation meets strict confidentiality standards. This often means carefully considering your word choice and included details.
Insurance Requirements
Meeting insurance documentation requirements while keeping notes clinically useful can feel like serving two masters. Missing or incomplete information can lead to rejected claims and payment delays, adding financial stress to an already demanding process.
Technology Adaptation
Learning new systems and adapting to digital workflows presents its own challenges. Electronic health records streamline the documentation process, but the long-term benefits of organized, accessible records always outweigh the initial learning curve.
Fine Tune Your SOAP Notes
Writing solid SOAP notes can streamline your counseling practice. The key to manageable, strategic documentation lies in finding your rhythm and sticking to the structure.
Treat your notes as a tool rather than a burden. When done thoughtfully, they become your ally in providing exceptional care and communication - helping you track progress, maintain continuity, and make informed clinical decisions.
