What are SOAP Notes in Counseling? (+ Examples) (2023)

What are SOAP Notes in Counseling? (+ Examples) (1)How do doctors or therapists track what is happening with a patient or client from one visit to the next?

How do these professionals communicate this information with other professionals also working with the patient or client?

Years ago, this type of communication was not easy. It often meant that a client had to remember from visit to visit what they said to one doctor and then to another.

Now, medical professionals use SOAP notes for this purpose. This type of note-taking system offers one clear advantage: consistent, clear information about each patient during each visit to a provider. When the providers are part of the same group, this information can be easily shared.

Before you read on, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

  • What Are SOAP Notes?
  • Why Are SOAP Notes Important?
  • Writing Your SOAP Notes
  • 2 SOAP Note Examples
  • 3 Useful Templates
  • A Take-Home Message
  • References

What Are SOAP Notes?

Professionals in the medical and psychological fields often use SOAP notes while working with patients or clients. They are an easy-to-understand process of capturing the critical points during an interaction. Coaches also can make use of SOAP notes, with some adaptations.

SOAP notes are structured and ordered so that only vital and pertinent information is included. Initially developed by Larry Weed 50 years ago, these notes provide a “framework for evaluating information [and a] cognitive framework for clinical reasoning” (Gossman, Lew, & Ghassemzadeh, 2020).

(Video) Soap Note Examples for Mental Health Counselors

SOAP notes are primarily the realm of medical professionals; however, as you continue reading, you will see examples of how you might adapt them for use in a coaching session.

To begin, the acronym SOAP stands for the following components:


During the first part of the interaction, the client or patient explains their chief complaint (CC). There might be more than one, so it is the professional’s role to listen and ask clarifying questions. These questions help to write the subjective and objective portions of the notes accurately.

The descriptor ‘subjective’ comes from the client’s perspective regarding their experiences and feelings. It might also include the view of others who are close to the client.

An example of a subjective note could be, “Client has headaches. Client expressed concern about inability to stay focused and achieve goals.”

Another useful acronym for capturing subjective information is OLDCARTS(Gossman et al., 2020).

  • Onset: When did the CC begin?
  • Location: Where is the CC located?
  • Duration: How long has the CC been going on for?
  • Characterization: How does the patient describe the CC?
  • Alleviating and aggravating factors: What makes the CC better? Worse?
  • Radiation: Does the CC move or stay in one location?
  • Temporal factor: Is the CC worse (or better) at a certain time of the day?
  • Severity: Using a scale of 1 to 10, 1 being the least severe, 10 being the most severe, how does the patient rate the CC?

Think back to when you have had an appointment with a doctor. How many of these questions did your doctor ask? Chances are, they asked all of them. These questions are part of the initial intake of information and help the doctor or therapist assess, diagnose, and create a treatment plan.

A coach can easily adapt this method to their sessions and exclude whatever does not apply.

For example, a life coach may not need to know or ask about location unless the client indicates that every time they are in a particular spot, they notice X. Here, the idea is shifted from a location in the body to a location in the environment.


The professional only includes information that is tangible in this section. In a clinical setting, this might be details about:

  • Vital signs
  • Physical exam findings
  • Laboratory data
  • Imaging results
  • Other diagnostic data
  • Recognition and review of the documentation of other clinicians

Some clinical examples include, “Patients heart rate is X.” “Upon examination of the patient’s eyes, it was found that they are unable to read lines X and X.”

In a coaching situation, a coach might include some of this information, but it depends on why the client is seeking assistance from the coach and the type of coaching. For instance, a health or fitness coach might want to note diagnostic details like vital signs before, during, and after exercise.

(Video) How to Write SOAP Format for Mental Health Counselors

Most coaches do not talk in terms of symptoms or signs, but if you happen to do so, then it is important to understand the distinction between them.

Symptoms are what the person tells you is going on physically, psychologically, and emotionally. They are the client’s subjective opinion and should be included in the “S” part of your notes.

Signs are objective information related to the symptoms the client expressed and are included in the “O” section of your notes.

Using the example from earlier, a coach might determine that the “S” is the client expressing concern over an inability to complete tasks and achieve a larger goal. The “O” is their observation that the client has no time-keeping devices.

After further discussion, the coach may discover that the client does not plan their day with any structured tool. They use sticky notes as reminders. Each of these small details might relate to the CC: an inability to stay focused and complete goals.

On the other hand, a medical doctor would assess the headache issue and test the person’s eyesight, especially if the patient does not already wear glasses.

The doctor might also explore whether the patient has attention deficit-hyperactivity disorder because the CC mentions “an inability to focus and achieve goals.”


In this section, the professional combines what they know from both the subjective and objective information. Here, the therapist or doctor identifies the primary problem, along with any contributing factors.

They also analyze the interaction between problems, as well as any changes. When finished, the clinician has a diagnosis of the problem, a differential diagnosis (other possible explanations), discussion, and a plan.

Coaches do not “diagnose” in the traditional sense. Their role is generally one of assisting a client in seeing what they typically already know, but with greater clarity and, perhaps, renewed purpose.


A plan is where the rubber meets the road. Working with the client or patient, the clinician creates a plan going forward. The plan might include additional testing, medications, and the implementation of various activities (e.g., counseling, therapy, dietary and exercise changes, meditation.)

In a coaching relationship, the coach works with the client to create realistic goals, including incremental steps. This plan includes check-in points and deadlines for each smaller goal and the larger one. The coach might assign homework just as a therapist would. Often the homework offers opportunities for self-reflection. It also provides practice and acquisition of a new skill.


There are other considerations and inclusions used in the medical field. Gossman et al. (2020) also point out several limitations regarding the use of SOAP notes, including:

  • The order places the less essential details at the top. It forces the clinician to lose time scanning for necessary information during subsequent visits.
  • There is no section addressing how conditions change over time.
  • There also is no assessment area for how the plan is working.

Why Are SOAP Notes Important?

What are SOAP Notes in Counseling? (+ Examples) (2)Cynthia Moreno Tuohy, executive director of the Association for Addiction Professionals, has highlighted the importance of quality SOAP notes for more than 40 years.

At the 2016 NCRG Conference on Gambling and Addiction, she covered SOAP notes and the elements of good documentation.

According to Tuohy (2016), good documentation includes:

  • Use of direct quotes from the patient or client
  • A distinction between facts, observations, hard data, and opinions
  • Information written in present tense, as appropriate
  • Internal consistency
  • Relevant information with appropriate details
  • Notes that are organized, concise, and reflect the application of professional knowledge

SOAP notes offer concrete, clear language and avoid the use of professional jargon. They include descriptions using the five senses, as appropriate. They also avoid value-heavy terms. Impressions made by the clinician are labeled as such and based on observable data. Written documentation is about gathering the facts, not evaluating them.

Documentation protects the medical and therapeutic professionals while also helping the client. Clear notes communicate all necessary information about the patient or client to all of the people involved in the person’s care. SOAP notes facilitate the coordination and continuity of care.

Writing Your SOAP Notes

The primary thing to keep in mind is that SOAP notes are meant to be detailed, but not lengthy. They are a clear and concise record of each interaction with the patient or client.

Following the format is essential, but it is possible to reorder it so that the assessment and plan appear at the top (APSO). Doing this makes it much easier to locate the information you might need during future meetings or appointments.

The following video by Jessica Nishikawa provides additional information regarding why SOAP notes are used, by whom, and how.

2 SOAP Note Examples

Your client Tom Peters met with you this morning. Your notes are as follows:

S: “They don’t appreciate how hard I’m working.”
O: Client did not sit down when he entered. Client is pacing with his hands clenched. Client sat and is fidgeting. Client is crumpling a sheet of paper.
A: Needs ideas for better communicating with their boss; Needs ideas for stress management.
P: Practice conflict resolution scenarios; Practice body scan technique; Go for a walk during lunch every day for one week.

Your client Rosy Storme met with you this afternoon.

(Video) Clinician's Corner: Writing a good progress note

S: “I’m tired of being overlooked for promotions. I just don’t know how to make them see what I can do.”
O: Client is sitting in a chair, slumped forward, and burying her face in her hands.
A: Needs ideas for better communicating her ideas with her boss; Needs ideas for how to ask for more responsibility; Needs ideas for tracking her contributions.
P: Practice asking for what you want scenarios; Volunteer for roles within the company that are unrelated to current job; Brainstorm solutions to problems employer faces.

3 Useful Templates

Numerous websites offer free SOAP templates. Most are designed for use in the medical professions, including client-centered therapy and counseling. Here are three templates you can use for a medical visit, therapy, or coaching session.

1. SOAP note for medical practitioners (Care Cloud, n.d.):

What are SOAP Notes in Counseling? (+ Examples) (3)

2. SOAP note for counseling sessions (PDF)

3. SOAP note for coaching sessions (PDF)

A Take-Home Message

Whether you are in the medical, therapy, counseling, or coaching profession, SOAP notes are an excellent way to document interactions with patients or clients. SOAP notes are easy to use and designed to communicate the most relevant information about the individual. They can also provide documentation of progress.

For clinical professionals, SOAP notes offer a clear, concise picture of where the client is at the time of each session. They contribute to the continuity of care and are a tool for risk management and malpractice protection. For the client, they provide documentation of their problem, diagnosis, treatment options, and plans.

What is your experience using SOAP notes? How have you applied them to your coaching practice?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.


(Video) Physical Therapy Soap Note Example

  • Care Cloud (n.d.) Free SOAP note template. Retrieved March 6, 2020, from https://www.carecloud.com/continuum/free-soap-note-template/
  • Gossman, W., Lew, V, & Ghassemzadeh, S. (2020, September 3). SOAP notes. StatPearls Publishing. Retrieved March 6, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK482263/
  • Nishikawa, J. (2015, October 17). SOAP notes [Video]. YouTube. https://youtu.be/9TZqTtbBVXc
  • Tuohy, C. M. (2016, September 25–26). Foundations of addiction treatment [Conference session]. 17th Annual NCRG Conference on Gambling and Addiction, Las Vegas, NV.


What is an example of a SOAP note? ›

An example of this is a patient stating he has “stomach pain,” which is a symptom, documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.

What is a SOAP note in counseling? ›

SOAP Notes are a type of note framework that includes four critical elements that correspond to each letter in the acronym — Subjective, Objective, Assessment, and Plan.

How do you fill out SOAP notes? ›

Tips for Effective SOAP Notes
  1. Find the appropriate time to write SOAP notes.
  2. Maintain a professional voice.
  3. Avoid overly wordy phrasing.
  4. Avoid biased overly positive or negative phrasing.
  5. Be specific and concise.
  6. Avoid overly subjective statement without evidence.
  7. Avoid pronoun confusion.
  8. Be accurate but nonjudgmental.

What are the 4 parts of SOAP? ›

SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.
Pertinent medical history, including the patient's:
  • Past medical and surgical history.
  • Family history.
  • Social history.

How long should a SOAP note be? ›

Your SOAP notes should be no more than 1-2 pages long for each session. A given section will probably have 1-2 paragraphs in all (up to 3 when absolutely necessary).

How do you write a SOAP note for counseling? ›

SOAP notes include a statement about relevant client behaviors or status (Subjective), observable, quantifiable, and measurable data (Objective), analysis of the information given by the client (Assessment), and an outline of the next course of action (Planning).

How do you write a good Counselling note? ›

5 Tips for Writing Better Therapy Notes
  1. Be Clear & Concise. Therapy notes should be straight to the point but contain enough information to give others a clear picture of what transpired. ...
  2. Remain Professional. ...
  3. Write for Everyone. ...
  4. Use SOAP. ...
  5. Focus on Progress & Adjust as Necessary.
Aug 13, 2020

How do you write a Counselling case note? ›

Know What to Write
  1. Write down information that will help jog your memory for the next session. ...
  2. Keep case notes objective. ...
  3. Leave out unnecessary details and filler.
  4. Note a client's appearance or outfit only if it is relevant to their treatment. ...
  5. Be mindful of your own perceptions and biases.
May 19, 2020

What is a SOAP note and how is it structured? ›

SOAP notes. Today, the SOAP note – an acronym for Subjective, Objective, Assessment, and Plan – is the most common method of documentation used by providers to input notes into patients' medical records. They allow providers to record and share information in a universal, systematic and easy-to-read format.

What do you put in the assessment part of a SOAP note? ›

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.

What is the most important ingredient in soap? ›

Water. Water is an essential ingredient. It's used to make a lye solution, which is combined with oil. The water helps the oil and lye complete the saponification process.

What are the 3 main ingredients in soap making? ›

There are 3 key ingredients in soap: oil or fat, lye and water.

What are the five types of soap? ›

Liquid Soap
  • Moisturizing Soap. Moisturizing soap has a moisturizing agent that helps moisturize your hands as you wash them. ...
  • Antibacterial Soap. Antibacterial soap has become increasingly popular because it kills all the bacteria on your hands if adequately used. ...
  • Natural Soap. ...
  • Chemical-Free Soap.
Feb 21, 2022

How do you present a patient's SOAP? ›

The SOAP format can help.
  1. Subjective Notes. For the subjective segment, lead with a one-sentence reminder of who your patient is. ...
  2. Objective Notes. Open this segment by discussing vital signs, including blood pressure, pulse, respirations, temperature, and oxygen saturations. ...
  3. Assessment Notes. ...
  4. Plan Notes.
Sep 1, 2019

What do Counselling notes look like? ›

Clinical notes should be brief and factual, containing concise details of what was discussed in session, and not the personal opinions of the therapist. Any referrals or other action taken regarding the session should also be documented in this type of notes.

What should I say in Counselling? ›

  • “Small” issues. It's easy to feel like you need to talk about “deep” or “serious” issues in therapy But remember, there's no “correct” topic to discuss in therapy. ...
  • Patterns and behaviors. ...
  • Present feelings. ...
  • Rumination. ...
  • Relationships. ...
  • Past traumas. ...
  • New life challenges. ...
  • Avoided thoughts and conflicts.

What is the most important keys to successful counseling? ›

Developing an empathetic connection with each client is key to moving forward in the therapeutic process, and is the core of an effective counselor-client relationship.

How do you write a good case note example? ›

Case notes usually require you to provide a summary of the case which outlines the relevant facts, explains the legal issues and the judge's reasoning (ratio). This is followed by a critique of the judge's decisions and a discussion of the implications of the case.

How do you write a case example? ›

Writing up your case study
  1. Introduce the topic area of the report.
  2. Outline the purpose of the case study.
  3. Outline the key issue(s) and finding(s) without the specific details.
  4. Identify the theory used.
  5. Summarise recommendations.

What are examples of presenting problems? ›

  • Anxiety.
  • Depression.
  • Mood changes.
  • Trouble falling or staying asleep.
  • Mood swings.
  • Social withdrawal.
  • Changes in eating habits.
  • Feelings of anger.
Jun 8, 2020

What makes a good soap? ›

A good bar soap balances hardness, lather quality, and moisturizing. Doing all three is tricky. Each of these properties comes from different fatty acids in the vegetable oils we use. Different oils make different contributions.

How do you make soap for beginners? ›

The basic process of making soap is:
  1. Mix water and lye, set aside to cool.
  2. Melt oils, set aside to cool.
  3. Blend lye water and oils to form a soap “batter”
  4. Pour into mold and let harden for a day.
  5. Turn out of the mold, cut into bars and let cure for 2-3 weeks.
Feb 7, 2020

What makes a high quality soap? ›

A high quality soap made with care and attention will result in a soap that does not cause irritation, even to those with dermatological issues or extreme sensitivities. This requires quality oils, a formula that is as simple as possible, and high quality, skin-safe essential oils or fragrance oils.

How to make soap step by step? ›

Step-by-Step Guide
  1. Step 1: Melt and Mix the Oils. Weigh out your solid oils and melt them in a saucepan over a low heat. ...
  2. Step 2: Mix the Water and Lye. ...
  3. Step 3: Mix the Oils with the Lye Water. ...
  4. Step 4: Bring the Soap Mix to Trace. ...
  5. Step 5: Add to the Mold. ...
  6. Step 6: Leave to Rest.
Sep 11, 2020

How do you make your own soap? ›

To make cold process soap, you'll heat your choice of oils in a soap pot until they reach approximately 100 degrees Fahrenheit. Then, you'll slowly add a lye-water mixture and blend the soap until it thickens to trace. After the mixture reaches trace, add fragrance, color, and additives, then pour it into a mold.

Which type of soap is most effective? ›

There is no evidence that antibacterial soaps are more effective than plain soap for preventing infection under most circumstances in the home or in public places. Therefore, plain soap is recommended in public, non-health care settings and in the home (unless otherwise instructed by your doctor).

What goes under a in a SOAP note? ›

A: Assessment

This section describes your interpretation of the session and your client's progress towards their goals. You should include: Your analysis of the subjective and objective information. Clinical and professional knowledge to interpret your client's problems.

What is included in the A section of SOAP notes? ›

A = Assessment.

Other components of “A” may include the following where appropriate: patient risk factors or other health concerns, review of medications, laboratory or procedure results, and outside consultation reports. P = Plan or Procedure.

How do you present a patient SOAP? ›

The SOAP format can help.
  1. Subjective Notes. For the subjective segment, lead with a one-sentence reminder of who your patient is. ...
  2. Objective Notes. Open this segment by discussing vital signs, including blood pressure, pulse, respirations, temperature, and oxygen saturations. ...
  3. Assessment Notes. ...
  4. Plan Notes.
Sep 1, 2019

Where does diagnosis go in a SOAP note? ›

The assessment section is where you document your thoughts on the salient issues and the diagnosis (or differential diagnosis), which will be based on the information collected in the previous two sections.


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