In mental health care, effective documentation plays a key role in ensuring the best outcomes for clients. The SOAP note, a structured format for recording important session information, serves as a vital tool in this process.

What exactly is a SOAP note, and how does it benefit both clients and clinicians in psychiatry and psychotherapy? More importantly, how can mental health professionals craft SOAP notes that are both informative and compliant with legal and ethical standards?

This article explores SOAP notes, examining their role in psychiatric care, breaking down the format, and providing practical examples to help you master this important skill. Whether you're an experienced clinician or just starting out, this guide offers the knowledge and tools to create SOAP notes that truly support your clients' healing journey.

Understanding the SOAP Note Format

SOAP stands for Subjective, Objective, Assessment, and Plan, each representing a key part of the note:

• Subjective: This section records the client's self-reported symptoms, feelings, and concerns, offering insight into their inner experience.
• Objective: Here, you document observable behaviors, clinical observations, and any relevant test results, providing a clear picture of the client's presentation.
• Assessment: This is where you offer your clinical interpretation, including a DSM-5 diagnosis if applicable, and evaluate the client's progress in treatment.
• Plan: Finally, you outline the next steps in the client's care, such as homework assignments, referrals, medication updates, and future session planning.

This structured format is widely used in psychiatric and multidisciplinary care settings because it offers a clear, organized way to communicate key information about a client's treatment, ensuring continuity of care and facilitating collaboration among providers.

When and How to Use SOAP Notes in Psychiatric Practice

SOAP notes play a vital role in psychiatric practice, helping document patient progress, treatment plans, and medication management. Here's a closer look at when and how to use SOAP notes effectively:

• Frequency: Write a new SOAP note after each patient visit, whether it's an initial session or a follow-up appointment. SOAP notes should also reference and align with the client’s treatment plan, which are ideally reviewed and updated at least every three months.
• Psychotherapy vs. Medication Management: While the core structure of SOAP notes stays the same, the emphasis may shift depending on the session type. In. In psychotherapy sessions, notes may highlight the subjective and assessment sections, covering the patient's emotional experiences, insights, and progress toward treatment goals. In medication management sessions, notes might concentrate more on the objective and plan sessions, documenting clinical observations, symptom severity scales, side effects, and any changes to the medication regimen.
• Practice Setting: Adjust your SOAP notes to suit the needs of your specific practice setting. In solo practice, you might have more flexibility in your note-taking style, whereas team-based or inpatient settings may require more standardized formats to help communication among providers. Regardless of setting, clarity, accuracy, and completeness remain critical.
• EHR Integration: Many electronic health record (EHR) systems include templates for SOAP notes, simplifying the maintenance of consistent documentation. Use these tools to streamline your note-taking process, but make sure to customize each note to reflect each unique patient encounter.

Each SOAP note should reflect the patient’s current presentation, clinical observations, and any relevant changes since the previous session. This includes documenting fluctuations in symptoms, shifts in functioning, and any emerging risk factors such as suicidal or homicidal ideation. Consistently writing clear, timely, and clinically relevant notes supports treatment continuity, facilitates collaboration across providers, and helps ensure that interventions remain responsive to the patient's evolving needs.

Writing the Psychiatric SOAP Note: Best Practices for Each Section

Creating a strong psychiatric SOAP note involves careful attention to detail and a focus on clinically relevant information. Let's break down the key components of each section and explore best practices for crafting a comprehensive and useful note.

Subjective:

• Client quotes: Include verbatim statements that capture the client's mood, concerns, and self-reported symptoms, such as "I feel like I'm in a fog most of the time."
• Mood and insight: Describe the client's emotional state and level of self-awareness. Note any changes in sleep, appetite, or medication concerns.
• Medication and psychosocial concerns: Note the client’s self-reported medication adherence, side effects, or concerns, as well as any significant stressors or life events impacting their mental health.

Objective:

• Mental Status Exam (MSE): Document key findings from the MSE, including appearance, speech, affect, behavior, and thought processes.
• Test scores: Record relevant assessment results, such as PHQ-9 or GAD-7 scores, to provide a quantitative measure of symptom severity.
• Collateral information: Note any information provided by family members, other providers, or case managers, when appropriate and with consent.

Assessment:

• Clinical formulation and diagnostic reasoning: Integrate the subjective and objective findings to assess diagnostic impressions. Note whether symptoms are improving, worsening, or stable.
• Risk assessment: Include any evaluation of suicide or violence risk, and document changes in risk status or protective factors.
• Response to treatment: Briefly summarize the client’s engagement in treatment, adherence to recommendations, and progress toward identified goals.

Plan:

• Next steps in treatment: Outline upcoming therapeutic focus, homework, interventions, or referrals.
• Medication management (if applicable): Document any medication changes, rationale, side effect monitoring, or labs ordered.
• Follow-up: Indicate when the next appointment is scheduled and whether any safety plans or contingency plans were reviewed.

When writing each section, prioritize concise, nonjudgmental language that focuses on clinically relevant details. Avoid speculation or personal opinions, and instead rely on observable facts and client reports. Aim for a clear, organized structure that allows other providers to quickly grasp the key information and make informed decisions about the client's care.

Common Pitfalls and How to Avoid Them

When writing psychiatric SOAP notes, it's easy to fall into some common traps that can compromise the quality and usefulness of your documentation. Here are a few pitfalls to watch out for and strategies to sidestep them:

• Over-reliance on templates: While templates can be a helpful starting point, it's important to customize each note to reflect the unique aspects of the client's presentation and treatment. Avoid simply filling in the blanks without adding clinical specificity.
• Vague assessments: Statements like "doing better" or "making progress" lack the precision needed for effective treatment planning. Instead, provide specific examples of how the client's symptoms or functioning have improved, such as "reported a 50% reduction in panic attacks this week."
• Omitting safety details: Thorough risk assessment plays a key role in psychiatric care. Always include details about the client's current risk status, including any changes in suicidal or homicidal ideation, and document the safety plan or interventions put in place. If the client denies experiencing risks such as suicidal or homicidal ideation, make sure to record this as it documents that a safety assessment was conducted
• Disconnected sections: Each part of the SOAP note should build upon the others, creating a cohesive narrative of the client's care. Make sure to link subjective reports with objective findings and tie them both to the assessment and treatment plan. For example, if a client reports worsening depression, this should be reflected in the objective section (e.g., flat affect, slowed speech), addressed in the assessment (e.g., “Symptoms consistent with a depressive episode, worsening since last visit”), and followed by an appropriate plan (e.g., adjusting medication, increasing session frequency, or introducing a new intervention). This continuity helps ensure clinical reasoning is transparent and care is well-coordinated.

To steer clear of these pitfalls, focus on specificity, clarity, and continuity in your SOAP notes. Take the time to review and refine your documentation, ensuring that each section paints a vivid picture of the client's current status and supports the ongoing treatment process. Remember, a well-crafted SOAP note is not only a legal and ethical requirement but also a valuable tool for delivering high-quality, personalized care to your clients.

Examples of a Psychiatric SOAP Note in Practice

To help show how SOAP notes work in psychiatric care, let's look at two sample cases: an adult client with Generalized Anxiety Disorder (GAD) and an adolescent with depression during a psychiatric medication visit.

Sample Case – Adult Client with Generalized Anxiety Disorder (GAD):

• S: Client reports persistent worry that feels uncontrollable, particularly at night. States, "I'm constantly worried and can't shut my mind off, especially at night. I keep thinking I’ll lose my job, and then I can’t sleep." Reports fatigue, difficulty concentrating during the day, and increased irritability. Denies current suicidal ideation or self-harm.
• O: Client appeared visibly anxious: tearful at times, wringing hands, avoided sustained eye contact. Speech mildly pressured with frequent topic shifting. Affect anxious and constricted. Oriented to person, place, and time. No psychotic symptoms observed. PHQ-9 score: 15 (moderate depression). GAD-7 score: 18 (severe anxiety).
• A: Client meets diagnostic criteria for Generalized Anxiety Disorder, with exacerbation likely driven by occupational stress and associated insomnia. Reports significant cognitive symptoms (e.g., difficulty concentrating) and emotional distress, with functional impairment in daily activities. PHQ-9 score (15) indicates moderate depressive symptoms; GAD-7 score (18) reflects severe anxiety. No evidence of psychosis, mania, or suicidal/homicidal ideation at this time. Client denies suicidal and homicidal ideation. Client is receptive to medication management if symptoms do not improve with behavioral interventions..
• P: 
  
  • Recommended implementation of grounding exercises and sleep hygiene strategies
  • Advised client to begin tracking worry patterns using a daily log
  • Discussed pharmacologic treatment options; will reassess in one week and initiate SSRI (e.g., sertraline 25 mg daily) if no improvement noted
  • Continue monitoring safety risks and conducting review of safety plan with client
  • Follow-up scheduled in one week to monitor symptoms and evaluate treatment response

In this example, the subjective section captures the client's own words, highlighting their primary concerns and the impact on their daily life. The objective section documents observable signs of anxiety, such as tearfulness and pressured speech. The assessment confirms the GAD diagnosis and identifies job uncertainty as a contributing factor, while also noting the effect on sleep. Finally, the plan outlines specific interventions, including grounding techniques and pharmacological treatment options, and schedules a follow-up appointment to monitor progress.

Sample Case – Adolescent with Depression (Psychiatric Medication Visit):

• S: Client states, “I feel numb most of the time. The meds don’t seem to be doing anything.” Reports continued low mood, difficulty getting out of bed, and decreased motivation for school or social activities. Denies suicidal ideation, self-harm, or changes in appetite or sleep.
• O: Presentation marked by flat affect and slow psychomotor responses. Minimal spontaneous speech. PHQ-9 score: 18, indicating moderately severe depressive symptoms. No evidence of psychosis or mania. Vitals within normal limits.
• A: Depressive symptoms appear to be worsening despite adherence to current SSRI regimen (sertraline 10 mg daily). Clinical picture consistent with inadequate therapeutic response. Client demonstrates insight and engagement in care. No acute safety concerns at this time.
• P: 
  
  • Increase sertraline dosage from 10 mg to 20 mg daily
  • Monitor for activation, gastrointestinal upset, or increased suicidal ideation as dosage increases
  • Maintain current safety plan; client and guardian advised on potential side effects and warning signs
  • Follow-up via telehealth in 3 days to assess tolerability and symptom trajectory
  • Continue PHQ-9 tracking to monitor clinical response

This SOAP note demonstrates the use of the format in a medication management context. The subjective section includes the adolescent's reported symptoms and concerns about the effectiveness of their current medication. The objective section notes observable signs of depression, such as flat affect and slowed psychomotor response, and includes a standardized assessment score (PHQ-9) to quantify symptom severity. The assessment indicates that the depression is worsening and suggests a possible need for medication adjustment. The plan outlines the specific dosage change, emphasizes monitoring for side effects, and schedules a prompt telehealth check-in to assess the client's response to the adjustment.

Incorporating SOAP Notes into Ethical and Collaborative Practice

SOAP notes play an important role in ensuring ethical and collaborative psychiatric care. Here are some key considerations for using SOAP notes in your practice:

• Confidentiality: Keep client information confidential when documenting sensitive details in SOAP notes. Make sure your notes are stored securely and only shared with authorized individuals, such as other members of the treatment team or legal authorities when required by law.
• Progress tracking: Use SOAP notes to monitor clients' progress over time, identifying patterns, setbacks, and milestones. This long-term view can offer valuable insights into the effectiveness of treatment interventions and support ongoing assessments.
• Legal and regulatory compliance: Keep detailed, accurate SOAP notes to prepare for potential audits, insurance reviews, or legal inquiries. Ensure your documentation complies with relevant laws, regulations, and professional standards, such as HIPAA and state-specific guidelines.
• Ethical decision-making: Use your SOAP notes to guide and record ethical decision-making by providing a clear, objective record of the client's presentation, treatment, and progress. This information helps make well-informed choices that prioritize the client's best interests and minimize potential harm.
• Collaboration with other providers: When working with other healthcare professionals, such as primary care physicians or specialists, SOAP notes can help facilitate smooth communication and coordination of care. Share relevant excerpts from your notes to ensure all providers have a comprehensive understanding of the client's needs and treatment plan.

Key Takeaways

While SOAP notes are a necessary part of psychiatric practice, it's important to see them as more than just a documentation requirement. They can be a valuable tool for enhancing client care. Here are some strategies to make your SOAP notes truly useful:

• Change your mindset: View SOAP notes as a chance for reflection and clinical accuracy, rather than just another administrative task. Use the writing process to clarify your thoughts, identify patterns, and gain new insights into your clients' needs.
• Develop efficient habits: Create a consistent routine that allows you to complete SOAP notes promptly after each session. Consider using templates, abbreviations, and technology tools to make the process smoother without sacrificing quality.
• Continuously improve your skills: Treat SOAP note writing as an ongoing area for professional growth. Seek feedback from colleagues, attend workshops or training sessions, and regularly review your own notes to find areas for improvement.
• Use technology wisely: Take advantage of EHR systems, voice-to-text dictation, and other tools to make the documentation process easier. These technologies can help you capture key details more efficiently, giving you more time for direct client care.

Remember, the ultimate goal of SOAP notes is to support high-quality, individualized care for your clients. Putting effort into crafting clear, concise, and clinically relevant notes can lead to better treatment outcomes and a more rewarding practice experience. Effective documentation is a key part of your professional toolkit.