SOAP Note Examples for Mental Health

SOAP notes are an essential tool for mental health professionals. They help track patient progress and document therapy sessions.

In this article, we’ll show you how to write a SOAP note for mental health. You'll also find sample SOAP notes, including counseling examples.

The acronym, SOAP, stands for Subjective, Objective, Assessment, and Plan.

The SOAP note format organizes patient information clearly and consistently.

Your note-taking ability probably wasn’t tested during your education in behavioral health.

That's why we’ve included basic SOAP note examples below. Each section comes with a clear explanation.

What Are SOAP Notes?

SOAP notes are a type of therapy note that falls under the progress note category. As part of clinical notes, they document in detail a patient’s:

• Diagnosis
• Symptoms
• Treatment
• Progress toward therapy

These notes are part of a patient’s medical records. They can be shared with other healthcare providers for coordinated care.

Progress notes, such as SOAP notes, follow a standard format. Mental health software, like Vagaro’s, offers an intuitive SOAP note feature that breaks this format down simply. There are actually three types of SOAP notes you can add with Vagaro, which this support article explains how to use.

For clarity, here is a breakdown of a standard SOAP note. It includes key information and the proper tone for each section.*:

Subjective

The subjective section of a SOAP note includes the patient’s complaints and history. It covers self-reported symptoms, feelings, and experiences. This section documents session discussions and may include direct quotes.

The goal of subjective information is to uncover your patient’s chief complaint (CC).

There may be more than one CC present, and your patient may not report on the primary one straight away. Ask as many relevant questions as possible.

In this section, you should uncover:

• Your client’s description of their current emotional state
• Any physical symptoms your client may be experiencing
• Recent life events that may be affecting your client’s mental health
• Your client’s sleep patterns, appetite, energy level & any other relevant information
• Relevant medical history, such as a history of present illness (HPI) and medications your patient may be taking

Remember to include only relevant information. Use only quotes from your patient or important people in their lives connected to their mood, motivation and awareness level. Always make sure these quotes are set apart with quotation marks.

Example for Therapist

Patient, Alex M., reports feelings of helplessness and depression. Alex says, “I just can’t control my thoughts and haven’t been sleeping well.” He reports becoming irritable when in public, saying, “I don’t understand what’s setting me off.” We discussed his sleeping habits, activity level, recent life events, and stressors affecting his mood and sleep.

In this example, the provider records the client’s self-reported symptoms and life context. This information helps in the assessment and planning stages of the SOAP note.

Objective

The objective section records observable and measurable patient data. Physicians use it for vital signs, physical exams, and test results.

As a mental health professional, document the patient’s appearance, behavior, speech, mood, body posture, and affect.

Stick to objective observations. Avoid assumptions, personal opinions, negative language, or unsupported statements.

Example for Therapist

Alex is cooperative, though he wore a downcast expression during the session and was prone to long pauses when answering questions.

The provider had to repeat several questions, suggesting Alex’s condition is affecting his focus. He would wring his hands and deflect whenever the subject of his military service came up.

In this example, the provider records the patient’s observable behavior and speech patterns. These details offer insight into the patient’s mental status.

Assessment

The assessment section combines subjective and objective data. It helps develop a diagnosis or clinical impression.

This section may include a summary of the patient’s symptoms and relevant history. You can document clinical insights on mood, orientation, and risk of harm. Also, include progress toward treatment goals.

Example for Therapist

Based on Alex’s self-report and observations during the session, the provider feels he is experiencing symptoms consistent with anxiety and major depressive disorder, with signs of PTSD. Lack of sleep exacerbates negative mood spirals and racing thoughts. The provider’s impression is that, while not yet severe, these symptoms are causing distress and impairment in Alex’s daily life and will worsen without intervention.

In this example, the provider reviews subjective and objective data. They use this information to form a clinical impression of the patient’s mental health.

Plan

In the plan section of your SOAP note, you’ll outline the next steps in your patient’s treatment. This field should include any interventions or treatments that will be implemented, as well as any referrals or follow-up appointments that are necessary.

You may note the expected therapy frequency and duration. Include short- and long-term goals. List any exercises assigned between sessions.

Example for Therapist

The provider will continue psychotherapy with Alex on Thursdays at 4 p.m. Alex agreed to attend a local veterans’ group therapy meeting to see if this helps, and report back at our next session. Mutually decided that, in the next week, Alex will contact someone, either a friend from before his time in the military, or someone with whom he served and is close to, to help feelings of isolation. Alex will begin a CrossFit training program, for enjoyment as well as an outlet for depression and negative thoughts. The provider will continue to build trust with Alex, and slowly broach his combat experiences, family history and other sources of stress. Alex was reluctant to begin taking medication. The provider will continue to monitor the severity of his symptoms and will discuss medication again if they worsen. In this example, the provider outlines realistic and measurable goals that they and their patient have agreed upon. Included are physical, social and medical attributes that will contribute to the patient’s therapeutic goals.

You might be wondering if SOAP notes are essentially the same for all mental health professionals (psychotherapist, counselor, etc.). Well, not quite.

While the basic structure remains the same (SOAP), the details and depth of each section may vary depending on the modality.

Let's explore the differences between hypothetical SOAP notes created by psychotherapists and counselors below.

SOAP Notes Example for Psychotherapist

Psychotherapists explore the client's psyche, unconscious processes, personality dynamics, and past experiences.

Their SOAP notes may include deeper analysis and focus on long-term goals. These goals often relate to personality change or resolving deep-seated issues.

Here’s an abbreviated example of a psychotherapist’s SOAP notes:

Subjective: Client, Alex, reported a longstanding pattern of anxiety, which has intensified recently due to work pressures. Described feeling overwhelmed, worthless, and fearing failure.

Objective: Alex appeared withdrawn, had difficulty maintaining eye contact, and exhibited low energy. Vital signs within normal limits.

Assessment: Alex presents with generalized anxiety disorder with potential underlying depressive symptoms. Defense mechanisms of avoidance and intellectualization noted.

Plan: Continue exploring Alex’s early childhood experiences related to anxiety. Introduce cognitive-behavioral techniques to challenge negative thought patterns. Consider referral for medication evaluation. Schedule follow-up in two weeks.

SOAP Notes Example for Counseling

Counselors might focus on short-term goals related to specific problems. Their SOAP notes may reflect practical problem-solving, coping skills, and improving overall well-being.

Here’s an abbreviated example of a counselor’s SOAP notes:

Subjective: Client, Alex, reported increased anxiety levels over the past week, specifically related to job performance. Described feeling overwhelmed, restless, and difficulty concentrating.

Objective: Alex appeared tense, exhibited fidgeting, and had a rapid speech pattern. Vital signs within normal limits.

Assessment: Alex is experiencing moderate anxiety related to job-related stressors. Coping mechanisms, such as relaxation techniques, seem insufficient now.

Plan: Continue exploring anxiety management techniques with Alex. Introduce progressive muscle relaxation. Develop a stress management plan. Schedule follow-up in one week.

The counselor's note focuses on immediate anxiety management strategies. The psychotherapist's note explores deeper issues and long-term treatment goals.

Therapists often incorporate elements from different approaches. The session's focus, therapist's orientation, and client's concerns shape the SOAP note's content.

Now, let’s look at examples of clinical depression and anxiety from both perspectives.

SOAP Notes Example for Depression

Depression (Psychotherapist)

Subjective: Client, Alex, reported persistent feelings of sadness, emptiness, and hopelessness for several months. Decreased interest in previously enjoyed activities, social withdrawal, and changes in appetite and sleep patterns. Reports difficulty concentrating, feelings of worthlessness, and recurrent thoughts of death without specific plans.

Objective: Alex presents with a flat affect, decreased eye contact, and slowed speech. Appears disheveled and withdrawn.

Assessment: Alex exhibits symptoms consistent with Major Depressive Disorder. Depressive symptoms are significantly impairing occupational and social functioning. Possible underlying unresolved grief and anger based on client's history.

Plan: Continue exploring Alex’s early life experiences and attachment patterns. Introduce psychodynamic therapy to uncover unconscious conflicts contributing to depression. Implement interpersonal therapy to address relationship difficulties. Consider medication consultation. Schedule follow-up in two weeks.

Depression (Counselor)

Subjective: Client, Alex, reported feeling sad and down for the past month. Decreased interest in hobbies, difficulty sleeping, and changes in appetite. Feeling overwhelmed and unable to cope with daily tasks.

Objective: Alex appeared downcast with decreased energy.

Assessment: Alex is experiencing symptoms of depression related to recent life stressors. Coping skills are overwhelmed.

Plan: Develop a daily routine with Alex to increase structure and activity levels. Teach relaxation techniques to manage stress. Introduce problem-solving skills to address current challenges. Explore support systems and encourage social connection. Schedule follow-up in one week.

SOAP Notes Example for Anxiety

Anxiety (Psychotherapist)

Subjective: Client, Alex, reported excessive worry and anxiety for the past six months. Difficulty concentrating, irritability, muscle tension, and sleep disturbances. Physical symptoms include palpitations, sweating, and shortness of breath. Avoids social situations due to fear of judgment.

Objective: Alex appears restless and agitated. Increased muscle tension and rapid speech. Difficulty maintaining eye contact.

Assessment: Alex presents with symptoms consistent with Generalized Anxiety Disorder. Anxiety is significantly impairing occupational and social functioning. Possible underlying attachment issues based on client's history.

Plan: Explore Alex’s early childhood experiences related to safety and security. Introduce psychodynamic therapy to address underlying anxieties. Implement exposure therapy to challenge avoidance behaviors. Consider medication consultation. Schedule follow-up in two weeks.

Anxiety (Counselor)

Subjective: Client, Alex, reported feeling nervous and worried most of the time. Difficulty concentrating, restlessness, and irritability. Physical symptoms include muscle tension and difficulty sleeping.

Objective: Alex appears tense and fidgety.

Assessment: Alex is experiencing symptoms of anxiety related to multiple stressors. Coping skills are inadequate.

Plan: Teach Alex relaxation techniques to manage physical symptoms. Introduce cognitive-behavioral techniques to challenge anxious thoughts. Develop a stress management plan. Encourage regular exercise and healthy lifestyle habits. Schedule follow-up in one week.

Final SOAP Note Checklist

As a mental health professional, follow these key guidelines when writing SOAP notes:

• SOAP notes should be concise, objective & relevant to your patient’s treatment plan.
• Ensure accuracy of dates, times, names & tenses. Avoid obscure abbreviations or colloquialisms.
• Always attribute patient statements with quotation marks and qualify subjective statements with evidence.
• Don’t erase or remove errors. Rather, use a strikethrough, identify that spot as an “error,” and correct it.
• Avoid moral judgments when describing your patient. Use terminology accepted in the mental health field.
• Write your SOAP notes promptly after the session to ensure accuracy and completeness.

Video Telehealth SOAP Notes

Progress notes are also required of telehealth sessions. Below are things to include in your SOAP notes if you are conducting therapy via telehealth:

• Session begin & end time
• A statement indicating that the session was provided via telehealth
• Your location, i.e, home vs. office (ensure that your location reflects the office address that your insurance company has on file).
• Names of all session participants (in the case of families, couples, etc..)
• Date of the next session
• The interventions
• Mental status of patient

*Disclaimer: These examples are intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

——– Proper patient documentation shows your competency as a clinician and illustrates how your patient’s needs have been addressed. While keeping them may seem tedious to some, they are necessary toward delivering the best treatment possible.

Vagaro’s HIPAA-compliant practice management software streamlines mental health SOAP notes and other patient documentation. All notes are automatically stored to a patient’s profile for easy future access. Going paperless with EMR patient notes & forms is just one way that Vagaro can help you run your private practice more efficiently and put patients first. Taking better care starts with Vagaro. Sign up for your FREE 30-day trial and see for yourself!