SOAP Note Template
Free SOAP note template for therapists and mental health professionals. Complete with sections for Subjective, Objective, Assessment, and Plan.
What is a SOAP Note?
A SOAP note is a structured method of clinical documentation used by healthcare and mental health professionals. The acronym stands for Subjective, Objective, Assessment, and Plan — four sections that organize patient information in a consistent, logical format. For comparison, see SOAP vs DAP vs BIRP formats.
Template
Subjective
Document the patient's self-reported symptoms, feelings, and concerns. Include direct quotes when relevant.
- Chief complaint
- History of present illness
- Patient's description of symptoms
- Relevant psychosocial context
Objective
Record observable, measurable clinical findings.
- Mental status observations (appearance, behavior, speech, mood, affect)
- Vital signs (if applicable)
- Test results or assessment scores
- Clinician observations during the session
Assessment
Provide your clinical interpretation and diagnostic impression.
- Diagnosis or diagnostic impression (DSM-5/ICD-10 codes)
- Progress toward treatment goals
- Risk assessment
- Clinical formulation
Plan
Outline the next steps for treatment.
- Interventions used in this session
- Homework or between-session activities
- Medication changes (if applicable)
- Next appointment date and focus
- Referrals
When to Use This Template
SOAP notes are ideal for:
- Individual therapy sessions — Track session-by-session progress
- Psychiatric evaluations — Document medication management visits
- Insurance documentation — Meet requirements for reimbursement
- Supervision — Share structured notes with clinical supervisors
- Audit preparation — Maintain compliant records
Tips for Writing Effective SOAP Notes
- Write notes the same day — Details fade quickly
- Be specific — "Patient reported feeling anxious about work deadlines" beats "Patient anxious"
- Separate observation from interpretation — Objective is what you see; Assessment is what you think
- Keep it concise — Notes should be thorough but not verbose
- Use consistent language — Develop standard phrases you reuse across notes
