SOAP Notes in Psychology: Format, Examples, and Best Practices

In psychology, SOAP notes give therapists a repeatable way to separate what the person reports, what the clinician observes, the clinical assessment, and the plan that follows. The format is widely used across healthcare and can work well in psychotherapy when it is adapted to the depth and continuity of therapeutic work.

This guide explains the general SOAP structure and the writing decisions that apply across presentations. For condition-specific samples, use the dedicated anxiety SOAP note example or depression SOAP note example.

What are SOAP notes?

SOAP is an acronym for four sections:

• S: Subjective. What the person reports about their experience, symptoms, context, concerns, or progress. Preserve their meaning without turning the section into a transcript.
• O: Objective. What you directly observe or can verify during the session. This may include presentation, engagement, speech, affect, behaviour, or completion of an agreed task.
• A: Assessment. Your clinical synthesis of the session. Connect the reported experience and your observations to the formulation, current risks, progress, and working hypotheses.
• P: Plan. What happens next. Record agreed interventions, between-session work, referrals, follow-up, changes in frequency, or topics to revisit.

A reusable SOAP note structure

Use the structure as a prompt, not as a requirement to fill every line:

Subjective: What did the person identify as most relevant today? What changed since the previous session?

Objective: What did you directly observe? Include only details that are clinically relevant.

Assessment: What is your current clinical understanding? How does this session connect with the formulation and treatment goals?

Plan: What was agreed? What should be reviewed, practised, monitored, or coordinated before the next session?

The final note should make sense to you when you return to the case later. It does not need to reproduce the sequence of the conversation.

A general SOAP note example

S: The person reports improved sleep on four nights this week. They completed the agreed morning routine on three days and noticed that starting with one manageable task made the rest of the day feel less overwhelming.

O: Engaged and oriented throughout the session. Speech was clear and appropriately paced. The person compared the three completed mornings with the days when the routine did not begin.

A: Early evidence that reducing the first step may support follow-through. Progress remains inconsistent, and self-critical responses after missed days continue to interfere with re-engagement.

P: Repeat the manageable morning step on three days and record what helped or obstructed starting. Review the response to missed days at the next session. Maintain the current session frequency.

This general example shows how the four sections work together without trying to represent a particular diagnosis. The dedicated examples explore the additional documentation decisions that arise around anxiety, depression, and risk.

SOAP note example for a follow-up session

S: The person describes fewer conflicts with their partner and reports pausing before responding during two difficult conversations. They remain concerned that setting limits will be interpreted as rejection.

O: Reflective and collaborative. Affect was congruent with the topics discussed. The person identified the sequence between perceived disappointment, guilt, and over-accommodation with less prompting than in earlier sessions.

A: Increased awareness of the interpersonal pattern and initial behavioural change. Fear of relational rupture continues to maintain difficulty with boundaries.

P: Practise one low-intensity boundary before the next session and note the anticipated and actual response. Revisit the distinction between responsibility and guilt.

What not to include

• A complete transcript. The note should select what matters for care rather than reproduce the whole conversation.
• Personal reactions without clinical relevance. Material for supervision should not automatically enter the clinical record.
• Unsupported conclusions about third parties. Record what the person reports and how it affects the case, not unverified judgments about someone who is not present.
• Interpretation presented as observation. Keep what you saw or heard in the objective section and place your clinical understanding in the assessment.
• Vague plans. “Continue working on anxiety” gives little support when you return to the record.

Common SOAP note mistakes

Making the subjective section too long

Capture the themes and changes that matter to the work. If the section reads like a chronological account of the session, it is probably carrying more detail than the record needs.

Treating “objective” as a mental status examination every time

Include observations that are relevant to the session and your setting. Repeating a full checklist without a clinical reason can make meaningful changes harder to see.

Writing an assessment that only repeats the first two sections

The assessment is where clinical judgment becomes visible. It should explain what the information means for the formulation, progress, risk, or treatment direction.

Leaving the plan disconnected from the assessment

The plan should follow from your clinical understanding. If the assessment identifies avoidance as the maintaining process, the next step should connect to that process.

SOAP, DAP, and BIRP notes

SOAP is not the only useful structure. DAP combines description before assessment and plan, while BIRP organises the record around behaviour, intervention, response, and plan. The best format is the one that supports your clinical reasoning, setting, and documentation obligations without forcing the session into the wrong shape.

See the comparison of SOAP, DAP, and BIRP notes for a closer look at when each structure is useful.

For more detailed writing decisions, review the fictional SOAP examples for anxiety and depression. They use the same headings but show why the content should change with the session rather than become reusable boilerplate.

For therapists practising in Spain

SOAP is a documentation structure, not a legal requirement. Spain's Law 41/2002 regulates rights and obligations concerning clinical information and documentation within its scope. The Code of Ethics of the General Council of Psychology also addresses the secure and confidential handling of retained psychological records.

The requirements that apply to a particular practice depend on the professional role, setting, autonomous community, and services provided. Use the format only when it fits those obligations, and seek guidance from your professional association or legal adviser when necessary.

Keeping SOAP notes clinically useful

Write close enough to the session that the relevant distinctions are still clear. Keep the person's account separate from your observations and assessment. Make the plan concrete, then review the note as part of the clinical record rather than treating the format as a finished answer.

Clara prepares an editable clinical note draft from the session, shaped around the therapist's orientation and left for professional review. See how Clara supports clinical documentation →