Clinical Note Template (SOAP)
A SOAP-format progress note template (Subjective, Objective, Assessment, Plan) adapted for psychotherapy, with prompts for what belongs in each section and what should be left out.
About this resource
The SOAP note originated in problem-oriented medical records and has become the most widely used structure for progress notes across health disciplines, including counselling and psychology. Its value is that it separates what the client reported from what the clinician observed, and both of those from the clinician's judgement and the plan. This separation makes notes easier to read, easier to defend, and easier to use for continuity of care.
Adapting SOAP to psychotherapy takes some care. The Objective section is not limited to measurable data: it includes observed affect, presentation, engagement and outcome scores. The Assessment section is where the clinician relates the session to the formulation and treatment plan, and where risk is explicitly addressed. The Plan section records the between-session task, the next appointment and any follow-up actions. This template gives prompts for each section and a short guide to common errors, such as recording opinion in the Subjective section or writing so much process detail that the note becomes a transcript.
The professional version adds guidance on documentation of risk, on what to include when a note may be read by the client or disclosed to a third party, and on keeping notes proportionate: enough that another competent clinician could pick up the case, and no more.
How to use it
- Write the note as soon as possible after the session, ideally the same day. Aim for a note that can be written in under ten minutes.
- Fill each section with only the content that belongs there. If you find yourself writing your interpretation in the Subjective section, move it to Assessment.
- Always complete the risk line in Assessment, even when there is nothing new to report. A note that is silent on risk is hard to defend later.
- Make the Plan concrete: the specific task agreed, the date of the next session, and any action you have committed to, such as a letter or a referral.
- Follow your regulatory college's documentation standards and your organisation's retention policy. This template does not replace them.
- Review a sample of your own notes periodically. Ask whether a colleague could understand the course of treatment from the notes alone.
References
- Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593-600.
- Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286-292.
- Beck, J. S. (2020). Cognitive Behavior Therapy: Basics and Beyond (3rd ed.). Guilford Press.
