A SOAP note is a structured method of documentation used by therapy professionals to record and organise client information during and after sessions. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan, which represent the four key sections of the note. This format is widely adopted across various healthcare and mental health disciplines for its clarity, consistency, and usefulness in clinical communication.
1. Subjective (S)
This section captures the client’s personal experience, thoughts, and feelings. It may include direct quotes, self-reported symptoms, concerns, or progress noted by the client since the last session. This narrative helps the therapist understand the client’s perspective and emotional state in their own words.
2. Objective (O)
Here, the therapist records observable, measurable facts. This could include the client’s behaviour during the session, mood, body language, or results from psychological tests or assessments. Objective data helps to balance the client’s subjective input with professional observations.
3. Assessment (A)
This section is the therapist’s clinical evaluation or interpretation of the session. It synthesises the subjective and objective information, identifies patterns, diagnoses, or progress, and reflects the therapist’s judgement on the client’s condition. This part is crucial for tracking therapeutic progress over time.
4. Plan (P)
Finally, the plan outlines the next steps. It may include proposed interventions, homework assignments, changes in therapeutic approach, or goals for the next session. It ensures continuity of care and gives both therapist and client a clear direction.
Why SOAP Notes Are Valuable for Therapy Professionals
Structure and Clarity: The format provides a consistent way to document sessions, making notes easier to read, review, and share with other professionals when needed.
Progress Tracking: SOAP notes allow therapists to monitor a client’s journey over time, identifying what interventions are working and where adjustments are needed.
Legal and Ethical Compliance: Accurate, well-organised notes can serve as legal documentation and support ethical standards of practice.
Communication: In multi-disciplinary teams, SOAP notes facilitate clear communication among professionals, ensuring coordinated care.
Efficiency: The structured nature of SOAP notes makes documentation more efficient, saving time without sacrificing detail.
For therapy professionals, SOAP notes are more than just a documentation tool — they are an essential part of delivering thoughtful, effective, and ethical care.