Trauma SOAP Note Example for Therapists

When working with trauma, the note needs to support continuity of treatment without becoming a detailed account of the event. It also needs to describe precisely what happens in session, such as a dissociative episode, and make clear which phase of treatment the work is in.

The example below is fictional and educational. It is not a diagnostic assessment or a risk assessment, and it does not replace professional judgement or applicable documentation requirements.

Fictional trauma SOAP note example

Context: Fourth session of trauma-focused treatment, in the stabilisation phase. Presenting concern: nightmares, startle responses and hypervigilance following a street assault eight months ago. Criminal proceedings are ongoing after she reported the assault.

Subjective: The person reports three nightmares this week related to the assault and difficulty getting back to sleep afterwards. She avoids the street where it happened and has changed her route to work. She explains that when someone walks behind her “her heart starts racing” and she needs to turn around. She has used the sensory grounding exercise twice, and on one occasion it helped her “come back to the present”.

Objective: Chooses the seat facing the door. Maintains eye contact intermittently. When mentioning a detail of the assault, her gaze becomes fixed and she takes a few seconds to respond to a question. She reorients with a guided grounding exercise, says she feels “back” and rates her distress at 4 out of 10 at the end of the session.

Assessment: The re-experiencing, avoidance and hyperarousal described in the initial assessment persist, consistent with the working hypothesis of post-traumatic stress disorder recorded at that time. In session there is a brief episode consistent with dissociation when approaching the memory, from which she recovers with guided grounding. This suggests that the window of tolerance remains narrow and that stabilisation should be strengthened before processing the memory. She is beginning to use regulation strategies independently.

Plan: Continue in the stabilisation phase. Practise sensory grounding daily and slow breathing before sleep. Record the frequency of nightmares and agree a routine for calming down after waking. Do not yet address the detailed account of the event. At the next session, review whether the conditions are in place to begin processing work.

Why it is written this way

The note does not include a detailed account of the assault. For continuity, it is enough to name the event and its relationship to the symptoms. Graphic details add nothing to the plan and increase the person's exposure if the record is accessed or requested later.

Dissociation is described by what was observed (fixed gaze, delay in responding, recovery with grounding), rather than simply labelled. Another person reading the note can understand what happened and how it was managed.

The assessment refers back to the hypothesis from the initial assessment and uses “consistent with”. A follow-up note is not the place to establish a new diagnosis.

The plan explains why the memory is not yet being processed. That clinical decision needs to be understandable when the case is reviewed. In post-traumatic stress after a single event, stabilisation should not be prolonged without reason; that is why the plan sets when to review it.

The ongoing proceedings are recorded in the context because the court may request a report or the clinical record. The note is limited to clinical facts and makes no judgements about what happened or about responsibility. The treating clinician should not also take on the role of expert witness.

The same session as a progress note

Fourth session, stabilisation phase. Three nightmares this week, avoidance of the area of the assault and hypervigilance in the street. Independent use of sensory grounding with partial benefit. In session, a brief episode consistent with dissociation when approaching a detail of the event, with recovery through guided grounding (final distress 4 out of 10). Stabilisation continues and processing of the memory is postponed. Review at the next session.

Questions to use during review

• Does the note avoid details of the event that are not necessary for care?
• Are dissociation and other states described by what was observed?
• Is the treatment phase clear, along with the reason for each decision?
• Does the assessment refer back to the previous assessment rather than diagnosing in a follow-up note?
• If there are legal proceedings, is the note limited to clinical facts, avoiding judgements about what happened or about responsibility?

See the SOAP notes guide and the guide to mental health progress notes. You can also compare this case with the grief example or the panic attack example.

Clara prepares an editable draft from the session. The clinician decides which details of the event should be recorded and reviews the description of what was observed before adding it to the record. See AI clinical notes with Clara.