Sample SOAP Note for Mental Health Therapists
Most mental health professionals come out of training still with some difficulty in understanding how to write a comprehensive SOAP, DAP or Progress note. How does one condense all that goes on in an hour of therapy into a simple, streamlined format which captures all the significant details of the session?(Click here to see a SOAP Note sample.)
One of the reasons for this confusion is that mental health counseling training focuses mainly on how to do therapy with the client. Specifically, how to assess, set goals and use various interventions to help the client reach their goals. The focus of training is not so much on how to document that information. The progress note (to be distinguished from a psychotherapy note) become a part of the client’s record. That means they could be subject to being included in a records request. Which is why it is important to understand the components of a good progress note.
This sample SOAP note is just that. An example of the clinically important variables that should be documented after each session. It is not a psychotherapy note that is part of the therapist’s processing and analysis of the client session. Therefore the SOAP note, DAP or progress note simply focuses on information that is relevant to the client assessment and treatment.
SOAP stands for Subjective, Objective, Assessment and Plan. Subjective data has to do with what the client says. Objective data has to do with what the counselor observed about the client in the session. Assessment is referring to the mental health counselors clinical conclusion about what the subjective and objective data mean. Plan is the action step both the counselor and the client are committing to. Plan can also include recommendations and referral information.
For example a sample SOAP note might look like this:
- S. The client reported, “I feel much better this week. I got up, exercised and enjoyed working in the yard.” CL reports she is ready for discharge soon.
- O. Counselor noted that client’s affect was improved, affect and cognitions were congruent, client completed homework on alleviating depression. Demonstrated good insight about the cause of her depressed mood and subsequent improvements. Client accomplished primary goal for counseling.
- A. Client’s mood has consistently shown improvement for 4 weeks. Symptoms of depression are eliminated.
- P. Begin discharge plan with client. Reschedule for 1 month for maintenance visit to monitor depression. If symptoms are alleviated at that time discharge client.