SOAP note framework
Use this reference when writing progress notes in Sessions Health. Every session note must follow the SOAP format and be finalized within 24 hours of the session.
Questions about documentation? Bring them to supervision.
S — Subjective
What the client reports
Include
- ✓ Chief complaint or presenting concern today
- ✓ Direct quotes from the client
- ✓ Self-reported mood, symptoms, life events
- ✓ Changes since last session (client-reported)
Exclude
- ✗ Your clinical interpretations
- ✗ Interventions you used
- ✗ Your observations of the client
Client reported feeling "exhausted and numb" following a conflict with their partner. Denies SI/HI. States they felt some relief after last session.
O — Objective
What you observe and do
Include
- ✓ MSE observations (affect, mood, behavior, orientation)
- ✓ Modality or intervention used (EMDR, CPT, DBT, etc.)
- ✓ Protocol details where relevant
- ✓ Measurable data (SUD score, PHQ-9, client response)
Exclude
- ✗ Your clinical interpretation of findings
- ✗ Treatment goals or forward-looking plans
Client alert and oriented ×4. Affect constricted, mood dysphoric. EMDR administered targeting partner conflict via taps. SUD pre: 7/10; post: 3/10. Tolerated well, no dissociation noted.
A — Assessment
Your clinical impression
Include
- ✓ Progress toward treatment goals
- ✓ Symptom trajectory (improving, stable, regressing)
- ✓ Clinical formulation and interpretation
- ✓ Risk level if applicable
Exclude
- ✗ Interventions used (that's Objective)
- ✗ What you will do next (that's Plan)
- ✗ Direct quotes from the client
Client demonstrates continued progress in affect regulation. SUD reduction 7→3 consistent with desensitization of target memory. Residual avoidance patterns remain. No safety concerns.
P — Plan
What happens next
Include
- ✓ Next session focus or target — be specific
- ✓ Homework or skill practice assigned
- ✓ Referrals or collateral contacts planned
- ✓ Current session frequency and any changes
Exclude
- ✗ Retroactive session content
- ✗ Vague entries ("continue therapy")
Continue EMDR targeting partner conflict memory next session. Client will practice 5-4-3-2-1 grounding between sessions. Continuing weekly frequency.
Quick reference — what goes where
| Section | Purpose | ✓ Include | ✗ Exclude |
|---|---|---|---|
| S | Client's voice — self-reported experience and reason for the session | Quotes, self-reported mood, presenting concern today, client-reported changes | Your observations, interventions, clinical interpretation |
| O | What you observed and what you did clinically | MSE, modality used, protocol details, measurable data (SUD, PHQ-9) | Your interpretation, forward-looking plans |
| A | Your clinical judgment — this is where your licensure earns its place | Progress, symptom trajectory, clinical formulation, risk level | Interventions, direct quotes, what happens next |
| P | Clinical direction going forward — declarative, not aspirational | Next session focus, homework assigned, referrals, session frequency | Retroactive session content, vague language |
→ Download printable PDF version
One-page reference card — print and keep in your office.