SOAP Note Template (Printable PDF)

In the subsequent 50 years, the SOAP note has been widely adopted by other health professionals, including mental health professionals, and remains one of the most popular progress note templates, both in private practice settings and in multi-disciplinary settings as it’s well-known and easy-to-use structure lends itself to efficient care-coordination between professionals.

The acronym SOAP stands for:

Subjective
Objective
Assessment
Plan

Components of a SOAP note template

Subjective component

The subjective component of the SOAP note consists of the clinician’s documentation of the client’s subjective presentation through clinical judgement and client self-report. Additional components may include:

• Presenting Problem: a brief statement of the client’s presenting problem
• History of the Present Illness: a brief review of the history of the client’s presenting problem
• General medical history: a brief overview of any relevant medical history not covered in the preceding sections
• Review of symptoms: documentation of any positive or negative symptoms the client is currently experiencing, by self-report or therapist observation and assessment

Example:
The client reports experiencing depression symptomology consistently for the past ten months, when in a short period of time he was laid off from his job and he experienced the death of his mother. He describes symptomology consistent with Major Depressive Disorder, Single Episode, Moderate, with the following symptoms occurring on most days over the past two weeks: depressed mood, sadness, crying spells, self-loathing, and lack of motivation

Objective component

The objective component of the SOAP note consists of the observable presentation of the client. These may include:

• Physical presentation
• Self-reported symptomology and observable signs
• Psychological status

Example:
The client presented as depressed with flat affect and reports a lack of motivation over the past week as he struggles to make progress on a search for employment. He displays signs of impaired memory in the immediate term as he reports difficulty recounting the experiences of the past week.

Assessment component

The assessment component of the SOAP note consists of the clinician’s assessment of any changes in the client’s psychological status since the last session, progress toward therapeutic objectives and goals, risk assessment (if necessary), and overall assessment of necessity of services. This may include:

• Changes in frequency or duration of symptomology
• Progress (or lack thereof) toward treatment objectives and goals
• Changes in risk assessment

Example:
The client reports no significant chance in frequency or duration of symptomology, though he noted difficulty with motivation in particular over the past week. He reported no progress toward his goal of improving self-direction as it relates to his job search. Client reported no suicidal ideation, intent, or plan since the last session and presents no indications to the contrary.

Plan component

The plan component of the SOAP note consists of any of the clinician’s planned case management efforts for the client, including referrals to other providers or other forms of care coordination, as well as the the clinician and client’s mutually agreed upon therapeutic plan until the next session. This section is often thought of as the therapeutic “homework” for the client.

The plan may include:

• Diagnosis
• Referrals
• Therapeutic assignments
• Next appointment date and time

Example:
Diagnosis: F32.1: Major Depressive Disorder, Single Episode, Moderate
Referrals: No referrals recommended at this time.
Assignments: The client plans to apply to three jobs over the next week as part of his goal of increasing self-direction.
Plan: Continue treatment plan.

Conclusion

A SOAP note is a great template for documenting progress in a therapy session. While SOAP notes have a generally understood layout — a section each for a subjective component, objective component, assessment, and plan — it’s important to note that there is no universal standard for a SOAP note, and therefore different practitioners or institutions may each have slightly different approaches to the format of a SOAP note. The SOAP note, then, is at once structured enough to allow for relatively easy care-coordination among professionals from different disciplines, while also being flexible enough to allow for interpretation and alteration.

Credits

Photo by Christin Hume on Unsplash