Mastering SOAP Notes: A Quick Breakdown
If anyone had ever peeked at my mock-therapy session notes, they might mistake them for a doctor's...no shade to doctors, but their handwriting is readable only by chemists 😅.
Jokes aside, if you’re an aspiring therapist like me or you want to master the art of therapy notes, consider this your handy pocket guide. SOAP stands for:
S: Subjective O: Objective A: Assessment P: Plan.
These notes are important because they keep your sessions organised, make progress easier to track, and support ethical documentation. They’re especially useful in CBT, REBT, Behaviour Therapy, Trauma-focused work, Expressive Arts Therapy, amongst others.
Firstly, let us understand the true essence of the above mentioned terms, where we have to delve deeper into what all that you as a therapist can include in the same !
💫 Subjective: What the Client Says
Once you have established a strong connection with your client, listen closely as they open up about their current challenges. These details belong in the subjective section. Capture not just the problems themselves, but also their intensity, how they began, what the client is feeling in the moment, and any other struggles they mention. Here’s a helpful tip: pay special attention to the client’s own words and phrases, and jot them down if they stand out.
💫 Objective: Therapist observations
Objective and self-observations come under this topic. As therapists, we are taught different types of “micro-skills,” right? Such as empathy, paraphrasing, attending, observation, among others. Here, you…as the therapist…notice the client’s subtle body language, their choice of words, and any other observable behaviour based on what they share with you, and make note of it.
💫 Assesment: Evaluation Summary
Now you’ve made a note of the presenting problems and recorded your own observations, it’s time for the assessment. Here, depending on the client’s issues, you can focus on certain major concerns they may be facing…such as anxiety, depression, OCD, IQ, attention span, among others. Based on the results, you can determine the severity of the issue and decide how to support the client moving forward.
💫 Plan: Future Steps
Get, set, plan. Here comes the Plan of Action …the part where both theories and interventions come together. This helps you map out the possible methods that can support the client. The methods you choose should help the client improve their condition, and you should make sure to note any changes along the way.
Tips for writing better SOAP notes
❗Wait for the session to end, and then start with your notes.
❗Do not focus on the length of the notes, but on the actual information.
❗Do not include any extra wordings, and stick to the point.
❗Remember to quote what your clients say.
❗Always proofread your notes, before finalizing them.
Finally, your SOAP notes should look similar to the example below…feel free to take a screenshot for your toolkit! Step by step, we can bring more order to our notes (and maybe even our lives). Ready for a small challenge? Try organising not just your life, but your session notes too! And to make it easier, Zensible offers ready-to-use SOAP-format notes that give you a solid base to build on, without starting from scratch each time. So get your Zensible subscription now! Until next time, take care of yourself and your mental health…whether you're a therapist in training or already making a difference.
