SOAP Note Template for Therapists: Structure, Filled Example, Common Mistakes
SOAP comes from medicine. It works well in talk therapy too, once you know what actually belongs in each section. Here's a template you can copy, a filled example, and the mistakes that show up most in real files.
If you trained in the last fifteen years, you've seen SOAP somewhere — one slide in a graduate seminar, maybe, wedged between two other topics. Then, in practice, everyone figured it out on their own. The result is wildly inconsistent files: pages of narrative from one clinician, three lines from another, and often no clear record of what was actually decided for the next session.
What SOAP stands for
SOAP is an acronym that splits a note into four sections:
- S — Subjective. What the client reports: their words, their complaint, how they describe the week, in their own terms.
- O — Objective. What you observe: presentation, affect, speech, behavior in the room, screening scores if you use them.
- A — Assessment. Your clinical read: working hypothesis, change since the last session, risk factors, connection to treatment goals.
- P — Plan. What's decided: direction for the next session, agreed tasks, coordination with a physician if relevant, the next appointment.
The format was built for somatic medicine, where "objective" means blood pressure and lab results. In talk therapy, the line between subjective and objective is blurrier, and that's exactly where most of the confusion starts.
Adapting each section to therapy
S — Subjective: the client's account, not yours
This section holds only what the client says about themselves — today's concern, what happened since last time, sleep, mood, energy, relationships, in their own terms. If they say "I haven't slept all week," record that they report insomnia over the week, optionally with their own words in quotes. What creeps in too often is interpretation slipped into the sentence: "client minimizes work difficulties" isn't subjective, it's assessment, and belongs in the A section.
O — Objective: what you actually saw and heard
Here you describe: presentation, eye contact, speech rate, affect (and whether it's congruent with what's being said), agitation or slowing, tearfulness, ability to stay on topic. Screening scores — PHQ-9, GAD-7, or whatever's part of your practice — go here, dated. The practical rule: a colleague reading your O should be able to picture the client in the room, without yet knowing what you make of it.
A — Assessment: your read, dated
This is where you're the clinician: connecting S and O to the history of the case. Is mood improving, holding steady? Does the working hypothesis still fit? Are there risk factors — suicidal ideation, self-harm, substance use — and how are you weighing them? Two traps here: rewriting the S in clinical language, and assigning a diagnosis at every single session. The A isn't a diagnosis — it's an evaluation of where the case stands today.
P — Plan: concrete, checkable
A useful plan fits in a few lines and lets you verify, next session, what actually happened. "Continue the work" isn't a plan. "Graded exposure: client commits to taking the bus twice this week, alone, during the day; review at next session" is. The P section also holds coordination — a call to the primary care physician with the client's consent, a letter to a psychiatrist, the date of the next appointment.
Copyable SOAP note template
Filled example (fictional case)
The case below is invented for illustration. It does not correspond to any real person.
The mistakes that show up most
- The S turns into a transcript. Everything said, in order — that's a recording, not a note. Keep what carries clinical weight.
- The O contains judgments. "Seems dishonest" isn't an observation. "Changes subject three times when the topic of her father comes up" is.
- The A repeats the S. A paraphrase of the narrative adds nothing; it needs to say what you make of it.
- The P is empty or vague. It's the most useful section for the next session, and for anyone who later picks up the file.
- Risk isn't documented. If you assessed suicide risk, write it down, even in one line. Silence on the question suggests it was never asked.
- What wasn't covered disappears. A line saying "not addressed today" prevents an important theme from getting lost three sessions later.
SOAP, DAP, BIRP: the difference in two sentences
| Format | Sections | When it fits |
|---|---|---|
| SOAP | Subjective · Objective · Assessment · Plan | Medical or institutional context, coordination with physicians, a format everyone already knows. |
| DAP | Data · Assessment · Plan | Private practice, when separating S and O feels artificial. Faster to write. |
| BIRP | Behavior · Intervention · Response · Plan | Behavioral approaches; when you want to track exactly what you did and how the client responded. |
There's no objectively best format. There's the one you'll actually keep up with, week after week. See our full comparison in DAP vs SOAP notes.
And the time it actually takes
A well-kept SOAP note takes ten to twenty minutes right after the session. Written from memory that evening, it takes longer and gets less reliable — exactly the moment Lectendo is built for. The session is transcribed (with the client's consent), a SOAP, DAP or BIRP note is drafted in the structure above, and what's left for you is what actually matters: read it, correct it, sign off. The Assessment stays yours; the tool never assigns a diagnosis, and writes "not addressed" rather than a guess.
This article is an educational resource on clinical documentation. It does not replace your training, your professional association's guidelines, or legal advice on record-keeping requirements in your jurisdiction.
Frequently asked questions
How long should a SOAP note be for a therapy session?
Half a page to one full page for a 45-60 minute session, in most practices. A longer note is rarely more useful — it's mostly slower to read back. What matters is that someone picking up the file understands where things stand.
SOAP, DAP, or BIRP: which one should I use?
SOAP if you coordinate with physicians or institutions that already use it. DAP if you want something lighter, without separating subjective from objective. BIRP if your approach is behavioral and you want to track interventions precisely. The most important thing is picking one and staying consistent.
Should I quote the client directly in a SOAP note?
Sparingly. A short quote, in quotation marks, can be valuable when the client's own wording carries clinical meaning. Paragraphs of verbatim speech add little and make the file harder to read later.
Is a SOAP note legally required for therapists?
No. What's typically regulated is keeping a clinical record at all — under HIPAA in the US, or professional record-keeping duties in the UK (GDPR plus your regulator's standards). The format itself is left to the clinician. SOAP is a convention, not a legal requirement.
A SOAP note drafted from your session, ready to review
Lectendo listens to the session (with the client's consent) or reads your transcript, and drafts a SOAP, DAP or BIRP note in your language. You review, correct, and sign off. 7-day trial, no card required, up to 30 minutes of audio and 5 notes included.
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