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How to Write SOAP Notes
What belongs in each SOAP note section, common mistakes in each, and a full worked example for a mental health session.
Updated August 29, 2026 · 9 min read
A well-written SOAP note documents a session clearly enough that another clinician — a supervisor, a covering provider, or you in six months — can understand what happened, why you made the clinical decisions you did, and what comes next. This guide walks through what belongs in each of the four sections, with a full worked example for a mental health session.
S — Subjective: what the client reports
The Subjective section captures the session in the client's own words and perspective — not the clinician's interpretation yet. This includes:
- The presenting concern or reason for today's session, in the client's framing
- Interval history — what's changed since the last visit (sleep, mood, stressors, medication changes if relevant)
- Direct or paraphrased quotes when they capture something clinically significant
- The client's self-reported symptom severity or subjective distress
Common mistake
Blending clinical interpretation into the Subjective section. “Client presents with worsening depression” is an assessment, not a subjective report. “Client reports feeling ‘more down than usual this week’ and difficulty getting out of bed most mornings” belongs in Subjective — it stays close to what was actually said and observed as reported, saving the clinical conclusion for Assessment.
O — Objective: what you directly observe
The Objective section is the clinician's direct observation — not what the client said happened, but what was observed in the room (or on the call). This includes:
- Appearance, affect, and mood as observed during the session
- Behavioral observations — eye contact, psychomotor activity, engagement level
- Mental status observations relevant to your scope and modality
- Any measured data — a PHQ-9 or GAD-7 score administered that session, for example
Common mistake
Treating Objective as a second Subjective section by restating what the client said rather than what was observed. “Client appeared tearful when discussing father's illness, minimal eye contact throughout, psychomotor retardation noted” is Objective. Repeating the client's account of their week is not.
A — Assessment: your clinical interpretation
The Assessment section is where the clinician synthesizes Subjective and Objective into a clinical picture: progress toward treatment goals, diagnostic considerations, and risk assessment when relevant. This is the section that demonstrates clinical reasoning — it should connect back to what was reported and observed, not appear disconnected from them.
- Progress toward treatment plan goals — improving, stable, or regressing, and why
- Diagnostic impressions or changes, when applicable
- Risk assessment findings, documented explicitly whenever risk is a clinical consideration — not just when it's elevated
- Clinical formulation connecting today's session to the broader treatment picture
Common mistake
A one-line Assessment (“client continues to struggle with anxiety”) that doesn't explain the reasoning visible in Subjective and Objective. A stronger version: “Client's GAD-7 score increased from 12 to 16 since last visit, consistent with reported increase in work-related stressors; anxiety symptoms appear situationally driven rather than a shift in baseline presentation.”
P — Plan: what happens next
The Plan section documents concrete next steps — this is what ties the note to future action and, in most outpatient practices, to billing and scheduling.
- Interventions planned for the next session or ongoing
- Homework or between-session tasks assigned to the client
- Any referrals made (psychiatric consult, medical follow-up, specialist referral)
- Next appointment timing and any changes to session frequency
- Follow-up plan for any risk considerations raised in Assessment
A full worked example
A SOAP note for a routine follow-up session, addressing generalized anxiety:
S: Client reports “a rough couple of weeks” at work, describing increased deadline pressure and difficulty sleeping (averaging 5–6 hours, down from her usual 7). Denies any change in appetite. States she has been using the breathing exercise from last session “a few times, when I remember.”
O: Alert, oriented, appropriately groomed. Affect mildly anxious, congruent with reported mood. Speech normal rate and rhythm. GAD-7 administered: score 14 (up from 10 two weeks ago).
A: GAD-7 increase consistent with client's reported situational stressor (work deadline). No indication of a broader symptom escalation outside this context. Client engaging inconsistently with between-session coping strategies. No risk concerns identified this session.
P: Continue weekly sessions. Review and reinforce breathing exercise with a specific daily trigger (e.g., before checking email each morning) to improve consistency. Introduce brief cognitive reframing exercise for deadline-related catastrophic thinking next session. Reassess GAD-7 in two weeks.
For more worked examples across different clinical scenarios — an initial intake, and a session involving a risk flag — see SOAP Note Examples for Mental Health →.
FAQ
- What goes in the Subjective section of a SOAP note?
- The Subjective section captures the session from the client's own perspective — the presenting concern, interval history since the last visit, and direct or paraphrased quotes, without clinical interpretation.
- What is the difference between Subjective and Objective in a SOAP note?
- Subjective is what the client reports in their own words. Objective is what the clinician directly observes — appearance, affect, behavior, and any measured data such as a screener score.
- What makes a strong Assessment section in a SOAP note?
- A strong Assessment connects back to what was reported and observed, explaining the clinical reasoning — progress toward goals, diagnostic considerations, and risk assessment — rather than a one-line summary disconnected from the Subjective and Objective content.
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