SOAP notes are a structured and standardized method used by mental health professionals to document psychotherapy sessions. The acronym stands for Subjective, Objective, Assessment, and Plan, providing a clear and concise format for tracking a client’s progress, treatment plan, and clinical observations. A well-written SOAP note enhances communication between professionals, ensures continuity of care, and serves as a legal record of therapy sessions.
This guide will provide a detailed example of a SOAP note for psychotherapy, breaking down each section with explanations and best practices.
SOAP Note Example in Psychotherapy
Client Information:
- Name: John Doe
- Age: 32
- Date of Session: February 12, 2025
- Therapist: Dr. Jane Smith, LCSW
- Session Number: 4
- Presenting Concern: Anxiety and workplace stress
S – Subjective
Client’s Report: John reports experiencing increased anxiety and difficulty concentrating at work. He states, “I feel overwhelmed with my workload and can’t seem to keep up.” He describes frequent racing thoughts and difficulty sleeping, saying, “I wake up several times a night thinking about all the tasks I need to complete.”
Emotional State: The client expresses feelings of frustration, self-doubt, and exhaustion. He rates his anxiety as 7/10 on a subjective distress scale.
Key Quotes:
- “I constantly feel like I’m behind, and no matter how much I do, it’s not enough.”
- “I get so stressed that I avoid certain tasks altogether.”
O – Objective
Therapist’s Observations:
- The client appeared tense, frequently wringing his hands and tapping his foot.
- Speech was clear but slightly rushed at times, especially when discussing work stress.
- No signs of psychosis or severe distress noted.
- The client maintained good hygiene and appropriate eye contact.
Behavioral Changes:
- Increased restlessness compared to previous sessions.
- Reports of avoidance behaviors (delaying work tasks due to stress).
- Noted improvements in emotional regulation techniques from previous session.
A – Assessment
Clinical Impressions: John continues to experience generalized anxiety, primarily work-related, with symptoms impacting daily functioning. His distress appears moderate but is showing some improvement through cognitive restructuring techniques learned in previous sessions. Avoidance behaviors indicate an ongoing challenge in managing stress.
Diagnosis:
- Generalized Anxiety Disorder (GAD) – Persistent worry and physical symptoms of anxiety affecting work performance.
Progress:
- Shows increased awareness of stress triggers.
- Partial improvement in emotional regulation but continued struggles with avoidance behaviors.
- Engaged and motivated in therapy.
P – Plan
Treatment Goals:
- Reduce workplace-related anxiety through cognitive-behavioral interventions.
- Improve time management and organizational skills.
- Increase use of mindfulness and relaxation techniques.
Interventions for Next Session:
- Introduce structured problem-solving techniques for work tasks.
- Continue practicing cognitive reframing exercises.
- Assign a small exposure exercise to address avoidance behaviors.
- Encourage daily mindfulness practice to improve emotional regulation.
Homework Assignment: John will use a daily planner to structure his tasks and practice prioritization. He will also track instances of avoidance and his emotional responses.
Next Session: Scheduled for February 19, 2025, at 10:00 AM.
Final Thoughts
A well-documented SOAP note ensures accurate tracking of a client’s therapeutic progress, helping both the therapist and the client achieve treatment goals effectively. By maintaining clear and structured records, mental health professionals can provide consistent and high-quality care while also meeting legal and ethical documentation requirements.