SOAP notes counseling
A SOAP note example is used in counseling to make note-taking more consistent and accurate and save time on writing notes from scratch. See a SOAP note example, get tips for writing SOAP notes and learn how to avoid common mistakes associated with SOAP notes.
What is a therapy SOAP note?
Therapy SOAP notes are the way you document that a client participated in and completed a session with you. Depending on the billing process you have, a completed therapy note may also be the way a claim is generated. Documentation also demonstrates your competency and shows how a client’s needs have been addressed.
Before talking about notes like therapy SOAP notes, know this: not all therapy notes are created equal. There are progress notes and there are psychotherapy notes.
Most therapists keep some form of therapy notes but they are very different and treated differently under HIPAA.
- Psychotherapy notes are detailed, private notes that a therapist may keep. Psychotherapy notes may contain observations, impressions and other details of the session. These notes do not follow a standard format and are stored separately. These types of notes have special protection under HIPAA and are NOT contained in the client’s record.
- Progress notes are part of the client’s record that provide details about the client such as diagnosis and assessment, symptoms, treatment and progress towards treatment goals. They follow a standard format (e.g., SOAP, BIRP, etc.) and ARE included as part of the client’s record.
What are the SOAP notes for mental health?
Most mental health clinicians utilize a format known as therapy SOAP notes. SOAP is an acronym that stands for:
S – Subjective
O – Objective
A – Assessment
P – Plan
Therapy SOAP notes are progress notes that contain specific information in a specific format that allows the reader to gather information about each aspect of the session.
Now, to be honest, most clinicians weren’t “trained” on therapy SOAP notes as part of graduate training. Chances are you picked up some therapy note-taking skills along the way. Some of you might be doing long, narrative notes that contain way more information than is appropriate for a progress note. (See progress vs. psychotherapy note descriptions above)
Therapy SOAP note example
Subjective: This section contains information relevant to what the client reveals in the session. This may be the client’s chief complaint, presenting problems and any relevant information. This information may include direct quotes from the client and things discussed during the session.
- Subjective soap note example: You may have discussed your client’s complaint of not sleeping well and sleep hygiene. Use words like “Discussed” or “talked about” or “reviewed” when describing things talked about in session.
Objective: The objective section contains factual information. Such objective details may include things like a diagnosis, vital signs or symptoms, the client’s appearance, orientation, behaviors, mood or affect.
- Objective soap note example: Client is oriented x4 (person, place, time, situation), client appears disheveled.
Assessment: This section is the place where you, as the clinician, document your impressions and interpretation of the objective and subjective information. This documentation may include clinical impressions related to factors such as mood, orientation, risk of harm as well as assessment of progress towards goals. Here you want to describe your impressions.
- Assessment SOAP note example: The client appears to understand the new goal.
Plan: This section documents what the next step is for the client. What do you, as the clinician, plan to do with the client at the next session? This is also the place to document things like the anticipated frequency and duration of therapy, short and long term goals as well as any new goals. Be sure to note any homework assignments or tasks you’ve given your client.
- Plan SOAP note example: Give referral
It sounds like an easy format to follow, but it does take some practice.
Complete SOAP note example
Download Your Free Therapy SOAP Notes Template
How do you write SOAP notes therapy?
As with any clinical documentation, you want to be sure you are including pertinent information. You also want to avoid errors that can at best be annoying and at worst, place you in legal jeopardy.
First, breathe. No therapy note is 100% perfect. Depending on who looks at it, there will always be something that could be written more clearly, more detailed, less detailed … something. The key is to write clear, thorough notes in a timely and consistent manner.
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Tips for writing solid progress 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.
Pay attention to spelling, person and tense.
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.
Be mindful of correct dates, times, spelling of names.
Avoid making subjective statements that cannot be substantiated. When making subjective statements, include pertinent evidence. For example, client appears anxious as evidenced by wringing his hands, excessive tapping of fingers, hyperventilation.
Never, ever alter a record using any type of correction eraser/tape/fluid/mark outs/scratch outs.
Consider concurrent documentation and writing your therapy SOAP notes during the session.
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How to correct a therapy SOAP notes error
Errors happen. Even the most careful note writer will make mistakes. If you find an error, resist the urge to just scratch it out or otherwise alter the record. Omissions, deletions and altered records create suspicion about its validity. The best way to correct an error is to use an accepted procedure for error correction. Here’s an example of one such procedure:
If you find an error, use a single strike-through (abc), write “error” next to it, and initial the error. Write in the correction and initial the correction. This way, the reader can see the original error, see the corrected information and see who made the correction. A word of caution: you want to be the one to correct your own records.
With a little practice, you can be a skilled progress note writer.
Resources
TheraPlatform, an all-in-one EHR, practice management and teletherapy tool offers progress note templates that take all the guesswork out of remembering all the details of therapy SOAP notes. Sign up for a free, 30-day trial with no credit card required. Cancel anytime.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
