Clinically Reviewed · April 2026by Melanie Matthews, RP
SOAP Notes for Therapists: Templates & Best Practices
Complete SOAP notes guide for mental health clinicians. SOAP note template, real examples, scoring integration, and how SOAP compares to DAP and BIRP notes.
Points à retenir
SOAP is the industry standard for mental health documentation (Subjective, Objective, Assessment, Plan).
Standardized assessment scores (PHQ-9, GAD-7) belong in the Objective section.
The Assessment section is for clinician interpretation, not just restating facts.
Notes should be completed within 24 hours to ensure accuracy and legal compliance.
SOAP notes (Subjective, Objective, Assessment, Plan) are among the most widely used clinical documentation formats in mental health and therapy settings. This guide covers how to write SOAP notes for therapists and counsellors, SOAP note templates for mental health, real SOAP note examples, and how SOAP compares to DAP notes and BIRP notes.
SOAP notes are a structured clinical documentation format used by therapists, psychologists, social workers, and other healthcare providers to record patient sessions. SOAP is an acronym for the four sections of the note:
Subjective (S), what the patient reports (mood, symptoms, stressors, quotes)
Assessment (A), clinical interpretation, diagnosis, progress, and risk level
Plan (P), next steps, interventions, referrals, next appointment
SOAP notes originated in medicine, developed by Dr. Lawrence Weed in the 1960s, and have since become among the most widely used documentation formats in mental health settings across North America.
The Subjective section captures the patient's perspective, what they report about their current state, in their own words. This is the patient's narrative, not the clinician's interpretation.
The Objective section contains measurable, observable data, information that is reproducible and not dependent on clinical interpretation. In mental health settings, this is where standardized assessment scores go.
The Assessment section is where the clinician synthesizes the subjective and objective data into a clinical interpretation. This is the clinician's professional judgment, not just a restatement of facts.
Date: 2026-04-24 Time: 14:00–14:45 (45 min, 90834)
Diagnosis: F33.1 Major Depressive Disorder, Recurrent, Moderate
Client: J.D., established, age 34
S: Subjective
Client reports mood "still pretty low most days but maybe a notch better than last visit." Sleep improved, averaging 6–7 hours from prior 4–5. Appetite normal. Denies SI. Reports starting morning walks 3×/week. Med tolerance good. No GI side effects on sertraline 100 mg.
O: Objective
PHQ-9 administered: 12 (down from 16 at last visit). GAD-7: 8 (down from 11).
Affect: mildly constricted but more reactive than prior. Speech: normal rate, prosody.
MSE: alert, oriented ×3. Insight and judgment intact. No suicidal ideation, plan, or intent.
A: Assessment
F33.1 in active treatment, showing clinically meaningful improvement (PHQ-9 -4 points). Comorbid F41.1 (GAD) also responsive. Activation behaviours (morning walks) consistent with behavioural activation strategy. No medication adverse effects to address. Risk: low. Item 9 negative, no recent ideation.
P: Plan
Continue sertraline 100 mg. Continue weekly behavioural-activation focused CBT. Reinforce activity scheduling. Re-administer PHQ-9 + GAD-7 at next visit (2026-05-01). Discussed sleep hygiene strategies. Client to track activation goals between sessions.
CPT: 90834 + 96127×2 (PHQ-9 + GAD-7)
This note bills 90834 (45-minute psychotherapy) plus 96127×2 (PHQ-9 and GAD-7). The Objective section records both scale scores and the Assessment compares them with the prior visit; CPT 96127 documentation needs both.
Date: 2026-05-08 Time: 10:00–10:55 (55 min, 90837, telehealth)
Diagnosis: F43.23 Adjustment Disorder With Mixed Anxiety and Depressed Mood
Client: R.S., established, age 52, session 4
S: Subjective
Client reports the layoff three months ago "still hits me most mornings," but job applications feel less daunting since setting a target of two a day. Sleep about 6 hours, broken. Appetite reduced. Spending more time with a former colleague. Denies SI.
O: Objective
Video session; client at home, alone, location confirmed. PHQ-9: 11 (15 at intake). GAD-7: 10 (13 at intake).
Affect: anxious, brightens when describing applications. Speech normal. MSE: alert, oriented ×3, goal-directed thought. No suicidal ideation, plan, or intent.
A: Assessment
F43.23 in active treatment with improvement on both measures (PHQ-9 -4, GAD-7 -3); both remain in the moderate range. Symptoms track the identifiable stressor (job loss) and ease as daily structure returns. Risk: low. Item 9 negative.
P: Plan
Continue weekly problem-solving therapy by video. Keep the two-applications-a-day target; add one social contact per week. Sleep: fixed wake time. Re-administer PHQ-9 + GAD-7 next session (2026-05-15). If both stay in the moderate range by session 8, review the diagnosis and treatment plan.
CPT: 90837-95 + 96127×2 (PHQ-9 + GAD-7)
Choose SOAP if you use standardized outcome measures (PHQ-9, GAD-7, etc.), work in a multidisciplinary setting, or bill insurance that requires structured documentation.
L'essayer avec un client
Envoyez un PHQ-9 ou un GAD-7 par lien sécurisé et lisez le résultat calculé avant la séance.
Mettez ce guide en pratique avec les soins axés sur la mesure
HiBoop administre et corrige les évaluations PHQ-9, GAD-7, PCL-5 et DASS-21, pour que les cliniciens consacrent le temps de séance aux clients, et non à la notation. Vous préférez un démarrage accompagné? Vous pourrez réserver une démonstration à la page suivante.