SOAP Note Examples for Mental Health

SOAP notes are an essential tool for mental health professionals. They help track patient progress and document therapy sessions.

In this article, we’ll show you how to write a SOAP note for mental health. You'll also find sample SOAP notes, including counseling examples.

The acronym, SOAP, stands for Subjective, Objective, Assessment, and Plan.The SOAP note format organizes patient information clearly and consistently.

Your note-taking ability probably wasn’t tested during your education in behavioral health. That's why we’ve included basic SOAP note examples below. Each section comes with a clear explanation.

What Are SOAP Notes?

SOAP notes are a type of therapy note that falls under the progress note category. As part of clinical notes, they document in detail a patient’s:

• Diagnosis
• Symptoms
• Treatment
• Progress toward therapy

These notes are part of a patient’s medical records. They can be shared with other healthcare providers for coordinated care.

For clarity, here is a breakdown of a standard SOAP note. It includes key information and the proper tone for each section.*:

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Subjective

The subjective section of a SOAP note includes the patient’s complaints and history. It covers self-reported symptoms, feelings, and experiences. This section documents session discussions and may include direct quotes.

The goal of subjective information is to uncover your patient’s chief complaint (CC).

There may be more than one CC present, and your patient may not report on the primary one straight away. Ask as many relevant questions as possible.

In this section, you should uncover:

• Your client’s description of their current emotional state
• Any physical symptoms your client may be experiencing
• Recent life events that may be affecting your client’s mental health
• Your client’s sleep patterns, appetite, energy level & any other relevant information
• Relevant medical history, such as a history of present illness (HPI) and medications your patient may be taking

Remember to include only relevant information. Use only quotes from your patient or important people in their lives connected to their mood, motivation and awareness level. Always make sure these quotes are set apart with quotation marks.

Example for Therapist

Patient, Alex M., reported feelings of helplessness and depression. Alex said, “I just can’t control my thoughts and haven’t been sleeping well.” He reported becoming irritable when in public, saying, “I don’t understand what’s setting me off.” We discussed his sleeping habits, activity level, recent life events, and stressors affecting his mood and sleep.

In this example, the provider records the client’s self-reported symptoms and life context. This information helps in the assessment and planning stages of the SOAP note.

Objective

The objective section records observable and measurable patient data. Physicians use it for vital signs, physical exams, and test results.

As a mental health professional, document the patient’s appearance, behavior, speech, mood, body posture, and affect.

Stick to objective observations. Avoid assumptions, personal opinions, negative language, or unsupported statements.

Example for Therapist

Alex was cooperative, though he wore a downcast expression during the session and was prone to long pauses when answering questions.

The provider had to repeat several questions, suggesting Alex’s condition is affecting his focus. He would wring his hands and deflect whenever the subject of his military service came up.

In this example, the provider records the patient’s observable behavior and speech patterns. These details offer insight into the patient’s mental status.

Assessment

The assessment section combines subjective and objective data. It helps develop a diagnosis or clinical impression.

This section may include a summary of the patient’s symptoms and relevant history. You can document clinical insights on mood, orientation, and risk of harm. Also, include progress toward treatment goals.

Example for Therapist

Based on Alex’s self-report and observations during the session, the provider felt he is experiencing symptoms consistent with anxiety and major depressive disorder, with signs of PTSD. Lack of sleep further exacerbates negative mood spirals and racing thoughts. The provider’s impression was that, while not yet severe, these symptoms are causing distress and impairment in Alex’s daily life and will worsen without intervention.

In this example, the provider reviews subjective and objective data. They use this information to form a clinical impression of the patient’s mental health.

Plan

In the plan section of your SOAP note, you’ll outline the next steps in your patient’s treatment. This field should include any interventions or treatments that will be implemented, as well as any referrals or follow-up appointments that are necessary.

You may note the expected therapy frequency and duration. Include short- and long-term goals. List any exercises assigned between sessions.

Example for Therapist

The provider will continue psychotherapy with Alex on Thursdays at 4 p.m. Alex agreed to attend a local veterans’ group therapy meeting to see if this helps, and report back at our next session. Mutually decided that, in the next week, Alex will contact someone, either a friend from before his time in the military, or someone with whom he served and is close to, to help feelings of isolation. Alex will begin a CrossFit training program, for enjoyment as well as an outlet for depression and negative thoughts. The provider will continue to build trust with Alex, and slowly broach his combat experiences, family history and other sources of stress. Alex was reluctant to begin taking medication. The provider will continue to monitor the severity of his symptoms and will discuss medication again if they worsen. In this example, the provider outlines realistic and measurable goals that they and their patient have agreed upon. Included are physical, social and medical attributes that will contribute to the patient’s therapeutic goals.

You might be wondering if SOAP notes are essentially the same for all mental health professionals (psychotherapist, counselor, etc.). Well, not quite.

While the basic structure remains the same (SOAP), the details and depth of each section may vary depending on the modality.

Let's explore the differences between hypothetical SOAP notes created by psychotherapists and counselors below.

SOAP Notes Example for Psychotherapist

Psychotherapists explore the client's psyche, unconscious processes, personality dynamics, and past experiences.

Their SOAP notes may include deeper analysis and focus on long-term goals. These goals often relate to personality change or resolving deep-seated issues.

Here’s an abbreviated example of a psychotherapist’s SOAP notes:

SOAP Notes Example for Counseling

Counselors might focus on short-term goals related to specific problems. Their SOAP notes may reflect practical problem-solving, coping skills, and improving overall well-being.

Here’s an abbreviated example of a counselor’s SOAP notes:

The counselor's note focuses on immediate anxiety management strategies. The psychotherapist's note explores deeper issues and long-term treatment goals.

Therapists often incorporate elements from different approaches. The session's focus, therapist's orientation, and client's concerns shape the SOAP note's content.

Now, let’s look at examples of clinical depression and anxiety from both perspectives.

SOAP Notes Example for Depression

Depression (Psychotherapist)

Depression (Counselor)

SOAP Notes Example for Anxiety

Anxiety (Psychotherapist)

Anxiety (Counselor)

Final SOAP Note Checklist

As a mental health professional, follow these key guidelines when writing SOAP notes:

• SOAP notes should be concise, objective & relevant to your patient’s treatment plan.
• Ensure accuracy of dates, times, names & tenses. Avoid obscure abbreviations or colloquialisms.
• Always attribute patient statements with quotation marks and qualify subjective statements with evidence.
• Don’t erase or remove errors. Rather, use a strikethrough, identify that spot as an “error,” and correct it.
• Avoid moral judgments when describing your patient. Use terminology accepted in the mental health field.
• Write your SOAP notes promptly after the session to ensure accuracy and completeness.

Video Telehealth SOAP Notes

• Session begin & end time
• A statement indicating that the session was provided via telehealth
• Your location, i.e, home vs. office (ensure that your location reflects the office address that your insurance company has on file).
• Names of all session participants (in the case of families, couples, etc..)
• Date of the next session
• The interventions
• Mental status of patient

*Disclaimer: These examples are intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

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Proper patient documentation shows your competency as a clinician and illustrates how your patient’s needs have been addressed. While keeping them may seem tedious to some, they are necessary toward delivering the best treatment possible.