Features
What Are SOAP Notes?
A SOAP note is a structured clinical documentation format — Subjective, Objective, Assessment, Plan — and how it differs from a general progress note.
Updated August 29, 2026 · 5 min read
A SOAP note is a structured format for clinical documentation, organized into four sections: Subjective, Objective, Assessment, and Plan. It's the most widely used note format across medicine and mental health, because it separates what the client reports from what the clinician observes, concludes, and plans to do next — a structure that makes a chart easier to read, defend in an audit, and hand off to another provider.
What each letter in SOAP stands for
- S — Subjective: what the client reports in their own words — symptoms, mood, concerns, and relevant events since the last visit.
- O — Objective: what the clinician directly observes — mental status, affect, behavior, and any measured data such as a screener score.
- A — Assessment: the clinician's clinical interpretation — progress toward treatment goals, diagnostic impressions, and risk considerations.
- P — Plan: what happens next — interventions, homework, referrals, and the plan for the following session.
For the full breakdown of what belongs in each section, with a worked example, see How to Write SOAP Notes →.
Where the SOAP format came from
The SOAP format originated in general medicine as part of the problem-oriented medical record, a documentation approach developed to make a patient's chart legible and consistent across different providers treating the same case. Mental health practice adopted the same structure because the underlying need is identical: separate what the client says from what the clinician clinically concludes, so the reasoning behind a treatment decision is visible to anyone who reads the chart later — a supervisor, a covering clinician, or an auditor.
Is a SOAP note the same as a progress note?
Not quite. “Progress note” is the general term for any note documenting a session or encounter — SOAP is one specific format a progress note can follow. A practice's progress notes might be written in SOAP format, or in a different structure such as DAP or BIRP, which organize similar clinical content slightly differently.
See SOAP vs DAP vs BIRP Notes → for how these formats compare and when a practice might choose one over another.
Who uses SOAP notes
SOAP notes are used across primary care, specialty medicine, and mental health — psychologists, therapists, counselors, and psychiatrists all commonly document sessions in this format, though the specific content within each section differs by discipline. A psychiatrist's Objective section might include a mental status exam and medication side-effect review; a therapist's might focus more on behavioral observations and engagement in session.
Where SOAP notes fit into a practice's broader workflow
A signed SOAP note isn't just a clinical record — in most outpatient practices it's also the source document billing pulls from, and the record a payer may request during an audit. See SOAP Notes and Insurance Billing → for how that connection works.
FAQ
- What does SOAP stand for in medical notes?
- SOAP stands for Subjective, Objective, Assessment, and Plan — the four sections of this clinical documentation format.
- Is a SOAP note the same thing as a progress note?
- "Progress note" is the general term for any note documenting a clinical encounter. SOAP is one specific format a progress note can follow — other formats include DAP and BIRP.
- Who uses SOAP notes?
- SOAP notes are used across primary care, specialty medicine, and mental health. Psychologists, therapists, counselors, and psychiatrists all commonly document sessions in this format, though the specific content in each section varies by discipline.
Try Ritaja Practice in your practice
Scheduling, clinical notes, PHQ-9 & GAD-7, billing, client portal, and telehealth in one Practice OS. 30-day free trial starts when you activate your clinic — no card required to sign up.
← All guides · What the software does · Why Ritaja Practice · Pricing