A SOAP note therapy example helps most when it looks like a real week in practice: a client who is getting better, a client whose risk went up, a teenager whose parent joins at the end, a member of a group. This guide has four complete SOAP notes from invented sessions like those, a rushed note rewritten line by line, a template you can copy, and a clear answer to the question most SOAP guides skip: where your interventions go.
Every client in this article is invented. Any resemblance to a real person is a coincidence.
What a SOAP note is, in one minute
SOAP stands for Subjective, Objective, Assessment, Plan. It is a progress note format: a short, structured record of one session. It started in medicine, as part of Dr. Lawrence Weed's problem-oriented medical record in the late 1960s, and moved into mental health later. That history explains two things you'll notice in many templates: some ask for vital signs, and most have no obvious place for the therapy you did in the session. More on that below.
In one line each:
- Subjective:what the client (or a parent or partner) told you.
- Objective:what you saw, measured and did in the session.
- Assessment:what it means, including progress toward treatment goals.
- Plan:what happens next.
A SOAP note is a progress note and part of the client's record. It is not a "psychotherapy note" in the HIPAA sense. That term covers notes kept separate from the record, and its definition leaves out session start and stop times, modalities, results of clinical tests, diagnosis, the treatment plan, symptoms and progress (45 CFR 164.501). Those are what a SOAP note holds. Clients can generally get a copy of their record, progress notes included (45 CFR 164.524), so write each note as if your client will read it.
What goes in each section
The NASW Code of Ethics asks social workers to keep records that are accurate and reflect the services provided, with "sufficient and timely documentation" for continuity of care and "only information that is directly relevant to the delivery of services" (NASW Code of Ethics, 3.04). The ACA Code of Ethics (A.1.b) and the APA Record Keeping Guidelines set a similar standard for counselors and psychologists. A SOAP note meets it in a few minutes when each section does its own job.
Subjective
The client's own account: the main concern this week, what changed since the last session, homework done or skipped, sleep, appetite, substance use when it's relevant, and what they said when you asked about safety. One or two short quotes say more than a paragraph of paraphrase.
When someone else is the source, name them: "Mother reports...", "Partner reports...", "Client reports her manager said...". Leave out your observations and your conclusions. "Client is in denial" is not something the client reported.
Objective
What a colleague in the room could have seen or counted: arrival and engagement, appearance, speech, affect, thought process, and scores on any measure, with the last score beside the new one. In therapy notes, Objective is also the natural home for what you did in the session and the response you could see or measure (more in the next section).
Leave out interpretation. "Affect anxious; picked at her nails" is an observation. "Anxious about her marriage" is a reading, and it belongs in Assessment. Delete medical fields that don't apply, such as vital signs, unless you actually took them.
Assessment
Your clinical reading. This is the section that makes SOAP worth using, and the one most often left thin. A good Assessment answers three questions:
- What is going on?A sentence or two tied to the diagnosis and treatment plan.
- How is it changing?Better, the same or worse, with the evidence from Subjective and Objective.
- Why is care still needed?The symptoms or limits in daily life (work, school, sleep, relationships) that therapy is addressing.
If you screened for risk, your judgment of the risk and your reasons belong here too. An Assessment that only repeats Subjective ("client reports feeling sad") isn't an assessment.
Plan
What happens next, written so it can be checked next week: homework with a number and a time frame, your focus for the next session, referrals or coordination of care, session frequency, the next date and format, and which treatment plan goals stay active. When risk is part of the picture, say what would change the plan.
Where interventions go in a SOAP note
This is the question SOAP guides answer differently, or not at all. In a medical visit, the treatment is usually a prescription or a procedure written in the Plan. In therapy, the treatment happens during the session, and SOAP has no section named for it. So some templates put interventions in Objective, some in Assessment and some in Plan.
Any choice can work if you use it every time. The examples in this article follow one rule:
- Objective:what you did in the session and the response you could see or measure, on lines labeled "Interventions" and "Response." Both are facts a colleague could have observed.
- Assessment:whether it is working and what that means.
- Plan:only what happens next.
If your practice puts interventions in Plan instead, split it into "This session" and "Next" so a reader can tell what happened from what is planned. Avoid hiding interventions inside Assessment, where they blur into your interpretation. Payers and auditors look for what you did and how the client responded, so wherever you put them, make them easy to find.
A SOAP note template you can copy
Paste this into your notes, delete what you don't need and keep the order. The header lines are what payers and auditors check first.
For telehealth, record where the client is: your license is tied to the client's location during the session, and you need the location if you ever have to send emergency help. Many payers also want the format (video or audio only).
SOAP note example 1: individual session for panic attacks
Invented client: a 41-year-old warehouse manager we'll call Marcus, in his sixth session of CBT for panic attacks. Since a panic attack on the highway in the spring, he takes side roads to work, which adds 40 minutes each way.
- Date of service: 10/20, 4:00 to 4:53 p.m., session 6
- Individual psychotherapy, in the office
- Treatment plan goal 1: drive the highway to work alone without turning back
Subjective: "I had one at the grocery store on Saturday, but I stayed in line." Client reports two panic attacks since last session (five in the week before intake), each lasting about ten minutes. Drove one highway exit with his wife in the passenger seat, as planned, with peak anxiety 7/10. Still takes side roads when driving alone. Cut coffee to one cup a day as agreed. Denies thoughts of harming himself or others when asked.
Objective: Arrived on time, well groomed, in work clothes. Speech normal in rate and volume; affect anxious at the start, brighter when describing the grocery store. Brought a complete seven-day panic log. Interventions: reviewed the panic log; reviewed the "false alarm" model of panic; interoceptive exposure in session, spinning in a chair for 60 seconds (three rounds) and breathing through a thin straw for two minutes (two rounds). Response: anxiety while spinning 6/10 on round one and 3/10 on round three. Rated the straw exercise 7/10 for similarity to his panic attacks; anxiety fell from 5/10 to 3/10 across the two rounds. Gripped the chair arm on round one and let go on round two after one prompt.
Assessment: Panic disorder improving with CBT. Attacks have dropped from five a week at intake to two, and he stayed in the situation both times instead of leaving. Fear of body sensations is falling with repeated exposure, shown by the drop in anxiety across rounds. Avoiding the highway alone is now the main barrier to goal 1 and still costs him 80 minutes a day. Continued weekly CBT is needed to reach goal 1.
Plan: Client will practice spinning and straw breathing for five minutes a day and log anxiety before and after. Drive one highway exit alone on two days, at a quiet time (step 3 on his list). Keep the panic log. Therapist will review the logs and plan step 4 (two exits alone) next session. Next session 10/27, 4:00 p.m., in the office. Goal 1 continues.
Why this note works:
- The opening quote shows progress in his words, and the numbers back it up.
- Every intervention in Objective has a measured response right beside it.
- Assessment doesn't repeat Subjective. It compares, explains and says why therapy is still needed.
- The Plan is the next step on his exposure list, so next week's note has something to check.
SOAP note example 2: telehealth session with a risk screen
Few published examples show the note that is hardest to write. This one records passive suicidal thoughts: what you asked, what the client said, how you judged the risk and what you did about it.
Invented client: a 47-year-old nurse we'll call Elena, in her ninth session for grief and depressive symptoms after her mother died four months ago. She had been her mother's main caregiver.
- Date of service: 10/21, 6:00 to 6:55 p.m., session 9
- Individual psychotherapy by video; client at home in Arizona, private room confirmed; home address and emergency contact (her sister) confirmed at the start
- Treatment plan goal 2: reduce depressive symptoms (PHQ-9 below 10)
Subjective: "Some nights I wish I could just go to sleep and not wake up." Client reports this thought on three nights this week, late at night after her children are asleep. When asked directly, she denies any plan, intent to act, preparation or past suicide attempts, and said, "I would never do that to my kids." Sleeping four to five hours a night. Worked three shifts and called in sick for one. Reports her mother's leftover prescription medications are still in a kitchen cabinet. Reports no firearms in the home.
Objective: Logged in on time by video. Dressed and groomed; tearful twice while describing her mother's last week. Speech soft but clear; thought process logical; no signs of intoxication. PHQ-9, completed online before the session: 16 (11 three weeks ago), item 9 scored 1 ("several days"). Interventions: asked directly about suicidal thoughts, plan, intent, preparation, past attempts and access to means; reviewed and updated her safety plan with her (warning signs, coping steps, people to call, crisis contacts including 988, and steps to make the home safer); talked through returning the medications to a pharmacy take-back site; grief-focused work on the guilt she named ("I should have seen it sooner"). Response: added two warning signs (lying awake after midnight, looking through old photos alone) and one coping step (calling her sister before 10 p.m.), and saved the plan as a photo on her phone. Agreed to drop off the medications at the pharmacy on Wednesday. Rated distress 8/10 while talking about her mother's last week and 5/10 at the end.
Assessment: Depressive symptoms have risen over three weeks (PHQ-9 11 to 16) as the first holidays without her mother approach. New passive suicidal thoughts, without plan, intent or preparation. Risk factors: recent loss, short sleep, medications at home (being removed). Protective factors: her children, close contact with her sister, no firearms at home, steady engagement in treatment. Clinical judgment: acute risk is low and can be managed in outpatient care with the updated safety plan and more frequent sessions; overall risk is higher than at intake. Symptoms are now affecting her work and sleep.
Plan: Increase to two sessions a week for two weeks; next session 10/23, 6:00 p.m., by video. Client will follow her safety plan, call her sister if the thoughts return, and call or text 988 or go to the nearest emergency room if she has any thought of acting on them. Client will take the medications to the pharmacy by Wednesday; therapist will confirm at the next session. Therapist will repeat the PHQ-9 and the risk questions each session and, with Elena's written consent, contact her primary care physician about her sleep. Goal 2 continues; risk monitoring added to the treatment plan.
Why this note works:
- Subjective records her answers to direct questions, and Objective records that the questions were asked, so no one has to guess.
- Assessment gives a risk judgment with its reasons, not just the words "low risk."
- The Plan says exactly what changes and what she will do if things get worse.
- Her location and emergency contact were confirmed at the start, which you need if you ever have to send help during a video session.
The safety plan in this example follows the steps of the Stanley-Brown Safety Planning Intervention, and the crisis contact is the 988 Suicide & Crisis Lifeline. How you assess and document risk is set by your training, your state and your practice's policy; this example doesn't replace them.
SOAP note example 3: a teenager with a parent check-in
Invented client: a 15-year-old we'll call Theo, in his fourth session for social anxiety that has led him to miss school. His mother joins for the last ten minutes of each session, as agreed at intake.
- Date of service: 10/22, 3:30 to 4:20 p.m., session 4
- Individual psychotherapy with a parent segment, in the office
- Goal 1: attend every school day. Goal 2: speak up in class once a week.
Subjective: Client: "Lunch is the worst part. Everyone already has a table." Missed one school day this week (three the week before). Asked a teacher a question after class, the first step on his list, and rated anxiety 6/10 before and 3/10 after. Denies thoughts of hurting himself. Mother (last ten minutes): he got up on time four of five mornings and has a stomachache "almost every morning"; on Thursday she drove him to school after he missed the bus. She reports his pediatrician found no medical cause for the stomachaches last month.
Objective: Arrived on time with his mother. Kept his hood up for the first ten minutes, then lowered it. Short, quiet answers at first; longer answers and good eye contact when talking about a game he plays online with a friend. Interventions: reviewed his exposure list; role-played asking to sit at a lunch table, twice; taught the anxiety curve (anxiety rises, peaks and falls when you stay in the situation). Parent segment: coached his mother to praise him for going to school and to follow the morning plan instead of offering to let him stay home when he has a stomachache. Response: rated anxiety 7/10 in the first role-play and 4/10 in the second. Chose sitting with his lab partner at lunch as his next step. His mother agreed to the morning plan and asked for a written copy.
Assessment: Social anxiety improving with graded exposure: absences dropped from three days to one, and he completed his first exposure step with a clear fall in anxiety. Morning stomachaches continue and are the main reason he asks to stay home; with no medical cause found, they fit the anxiety pattern. His mother is letting him stay home less. Progress toward goal 1; goal 2 not yet started.
Plan: Theo will sit with his lab partner at lunch on two days and ask one question in or after class. His mother will follow the morning plan, praise attendance and keep an attendance log. Therapist will email the written morning plan to his mother and, with his mother's signed consent and Theo's agreement, contact the school counselor about a quieter lunch option. Next session 10/29, 3:30 p.m., in the office, with a ten-minute parent check-in. Goals 1 and 2 continue.
Two things to watch with minors. First, label who said what: the teen's report and the parent's report can differ, and both matter. Second, agree at intake what you will share with parents (for example, attendance and the plan but not session content, with safety concerns always shared) and write the note so it respects that agreement. Depending on your state, a parent may have the right to read a minor's record.
SOAP note example 4: one member of a group
In a group, write a separate note for each member, in that member's own record. The group's topic and your interventions can be the same paragraph in every note; Subjective, the member's response, Assessment and Plan belong to that member alone. Refer to other members without names or details that could identify them.
Invented client: a 32-year-old graphic designer we'll call Kim, in an adult DBT skills group.
- Date of service: 10/22, 6:00 to 7:30 p.m.
- Group psychotherapy, in the office; seven members, one leader
- Group topic: Check the Facts and opposite action (emotion regulation module, week 3)
- Treatment plan goal: use skills instead of quitting or withdrawing when she feels criticized
Subjective: Client reports a strong urge to quit her job on Tuesday after a critical email from her manager (urge 8/10 on her diary card); she did not act on it. "I used to just walk out." Diary card shows self-harm urges at 0 to 1 all week, with no self-harm.
Objective: Arrived five minutes late; diary card completed for six of seven days. Group interventions: five-minute mindfulness exercise; diary card review in pairs; teaching on Check the Facts with a worksheet; rehearsal of opposite action for shame; homework assigned. Response: volunteered the email as her example. With one prompt, separated the facts ("the email asked for one correction") from her reading ("she's about to fire me"). Rated shame 8/10 at the start of the exercise and 5/10 after. Said "that's exactly me" when another member described a similar situation.
Assessment: Kim can use Check the Facts in session with one prompt, and her diary card shows she rode out a strong urge to quit without acting on it. No self-harm this week. Progress toward her goal; using the skill on her own, outside the group, is the next test.
Plan: Use Check the Facts at least twice this week when shame reaches 6/10 or higher, and record each time on the diary card. Continue weekly group and individual therapy. Group leader will share this week's summary with her individual therapist, as her release of information allows. Next group 10/29, 6:00 p.m.
Before and after: fixing a rushed SOAP note
Here is a note written in two minutes between clients, for an invented session with a 38-year-old client we'll call Sam, seen by video for insomnia and work stress.
Before:
- S: Client said she had a stressful week.
- O: Client appeared tired and anxious.
- A: Client is making progress.
- P: Continue therapy. Practice relaxation.
Every line may be true, and none would help a colleague, a payer or you next month. The same session, written well:
Subjective: "I'm up at 3 a.m. going over deadlines." Sleep diary (six of seven nights logged) shows about five hours a night, and more than an hour to fall asleep on work nights. Missed two work deadlines this month. Denies thoughts of harming herself or others.
Objective: On time by video from her parked car, alone. Yawned often; eyes red; speech normal; affect anxious, brighter when describing a weekend hike. Interventions: reviewed the sleep diary; taught stimulus control (bed only for sleep, get up after about 20 minutes awake); set a fixed wake time. Response: agreed to a 6:30 a.m. wake time every day; unsure about getting up at night ("It's cold").
Assessment: Insomnia kept going by work worry and long stretches awake in bed; no change in total sleep since intake. Daytime tiredness is now affecting her work. Engaged and willing to try the new routine; getting out of bed at night is the likely sticking point.
Plan: Wake at 6:30 a.m. every day; get up after about 20 minutes awake and return when sleepy; keep the sleep diary. Therapist will review the diary and adjust the plan next session, in one week by video. Goal 1 (at least six hours of sleep on most nights) continues.
What changed:
- "Stressful week" became a quote and numbers from her sleep diary.
- "Tired and anxious" became what you could see.
- The interventions, missing from the first version, are named, with her response.
- "Making progress" turned out to be wrong: total sleep hasn't changed yet, and the new Assessment says why.
- "Practice relaxation" became a plan with a time, a rule and a log.
Is it S, O, A or P? A quick sort
Most of the work of learning SOAP is deciding where a line goes. Cover the bold answers and try these.
- "I haven't slept more than five hours since Tuesday." S: the client's own report, in quotes.
- Kept her coat on and checked her phone four times in the first ten minutes. O: you saw it.
- GAD-7 total 13, completed online before the session (16 two weeks ago). O: a measured score, beside the last one.
- Client says her husband told her she "seems on edge all the time." S: someone else's words, attributed.
- Sleep loss appears driven by late-night work email and worry about a job review. A: your reading.
- Taught a wind-down routine; client chose 9:30 p.m. as her email cutoff. O: what you did and her response.
- Client will stop checking email after 9:30 p.m. on at least four nights. P: checkable, with a number.
- "Client seemed unmotivated." Nowhere yet: rewrite it as something you saw or heard ("arrived without the log; said, 'I didn't get to it'") and put it in O or S.
Words and phrases for each section
Subjective
- Starters: "Client reports...", "Client states...", "Client describes...", "Client denies...", "Mother reports...", "Partner reports..."
- Put the client's words in quotation marks so no one mistakes them for yours.
- Give changes a time frame: "since last session," "three nights this week," "over the past month."
Objective
- Appearance: well groomed, disheveled, dressed for work, dressed for the weather.
- Engagement: on time, late, logged in from a private room, attentive, guarded, gave short answers, volunteered examples.
- Speech: normal rate and volume, rapid, pressured, slow, soft, hesitant.
- Affect: flat, restricted, tearful, anxious, irritable, bright, congruent or incongruent with content.
- Thought process: logical, goal directed, tangential, circumstantial.
- Measures: "PHQ-9 16 (11 three weeks ago)," "GAD-7 13 (16 two weeks ago)."
- Interventions and response: "Role-played asking to join a table; anxiety 7/10, then 4/10," "Practiced the skill twice; needed one prompt."
Assessment
- Progress: "improving, as shown by...," "no change since intake," "symptoms have risen since...," "goal 1 met."
- Reading: "symptoms fit the pattern of...," "kept going by avoidance and...," "the main barrier to goal 1 is..."
- Need for care: "Continued weekly therapy is needed to address [symptom], which limits [work, school, driving, sleep]."
- Risk: "Passive thoughts of death without plan or intent; acute risk judged low because...; see plan."
Plan
- Homework with numbers: "on two days," "five minutes a day," "at least twice."
- Your next step: "review the log and plan step 4."
- Frequency and date: "weekly," "twice weekly for two weeks," "next session 10/27 by video."
- Coordination, with consent: "with written consent, contact the school counselor."
- A trigger for change: "if the PHQ-9 rises again, reassess risk and session frequency."
How long a SOAP note should be, and what tense to use
For a routine 45 to 60 minute session, most therapy SOAP notes run about 150 to 400 words: two to five sentences per section. Risk, crisis, intake and family sessions need more. A short note that names what you did and what changed is easier to defend than a long one that doesn't.
Write Subjective, Objective and Assessment in the past or present tense ("reports," "affect was flat") and the Plan in the future ("Client will..."). Pick one style and keep it.
A routine that keeps most notes under ten minutes:
- In the last few minutes of the session, agree on the Plan with the client out loud.
- Right after, write Objective first, while what you saw, measured and did is fresh.
- Write Subjective next, with one quote.
- Then write Assessment: compare with last week and say what it means.
- Add the Plan you already agreed, run the checklist below and sign the same day.
Common SOAP note mistakes in therapy
- Interpretation in Objective."Client was defensive" is a reading. Write what you saw and let Assessment interpret it.
- An Assessment that repeats Subjective.If you deleted Subjective, Assessment should still say something new.
- No interventions anywhere.SOAP has no section named for them, so they're easy to leave out. Payers look for them.
- Medical fields that don't fit.Vital signs and physical exam lines in a therapy note invite questions if you didn't take them. Delete what you didn't do.
- A risk screen with no follow-through.If a client reports thoughts of suicide, the note should show your judgment and what you did.
- "Continue weekly therapy" as the whole Plan.Say what the client will do, what you will do and when you'll meet.
- Copying last week's note.Copied notes suggest nothing changed, or that nobody looked.
- Missing session details.Date, start and end time, who attended, format and, for telehealth, the client's location belong on every note.
Before you sign: a SOAP checklist
- Does Subjective have at least one quote or specific report, with the source named?
- Is every label in Objective backed by something you saw or measured?
- Are this session's interventions named, each with the client's response?
- Is each score shown beside the previous one?
- Does Assessment say something Subjective doesn't: progress, the reason and why care is still needed?
- If you asked about safety, are the answers, your judgment and your actions recorded?
- Does the Plan have a number, a time frame, the next session and the goal status?
- Are the date, times, attendees, format and telehealth location there?
- Would you be comfortable if the client read it?
SOAP, DAP, BIRP or GIRP: which one to use
- Choose SOAP when you work alongside medical providers or a team that already uses it, or when keeping the client's account apart from your observations matters (minors with parents, couples, families, risk).
- Choose DAP when you want the shortest structured note; Data holds both the account and your observations.
- Choose BIRP when your work is technique-led and you want interventions and the client's response in their own sections. Our BIRP note examples show one session written as BIRP, DAP and SOAP side by side.
- Choose GIRP when each session is organized around a treatment plan goal.
- Whichever you choose, use it consistently for each client. Payers and auditors care about what the note contains, not which letters it uses.
How this works in TranqBay
TranqBay is practice software for therapists in private practice: booking, video sessions, session notes and a practice website in one place. Here is where a SOAP note fits.
- Choose SOAP for the session. When you add a note to a session, you pick its format: SOAP, DAP, BIRP, GIRP, or a blank note in your own words.
- A short prompt under each heading. Subjective asks what the client reports; Objective, what you observed (appearance, mood, affect, speech); Assessment, your clinical reading and progress toward goals; Plan, the next steps, homework, referrals and next session focus.
- The session details sit beside the note. The session's date and time, duration and modality, and the client's presenting concerns, are next to the note, so the header lines are already in front of you.
- Notes stay with the session. Each finished session lists its notes with their format, so last week's Plan is easy to find before this week's session.
- Measures before the session. TranqBay's form library has ready-made templates, including the PHQ-9, GAD-7, PC-PTSD-5 and AUDIT-C, intake forms and consent forms, which clients fill in online before a session. TranqBay doesn't score them: add up the total yourself and record it in Objective beside the last score.
- Structured formats such as SOAP are part of the advanced note templates, which some plans include.
To see how a session note sits next to the booking and the video session, look at the walkthrough on practice.tranqbay.health.
Frequently asked questions about SOAP notes in therapy
What does SOAP stand for in therapy?
Subjective, Objective, Assessment, Plan. Subjective is what the client reports, Objective is what you observed, measured and did, Assessment is your clinical reading, and Plan is what happens next.
Where do interventions go in a SOAP note?
There is no single standard. Many therapists put them in Objective with the client's response, as the examples above do; others put them in Plan under "This session." Choose one place and use it in every note.
Should PHQ-9 and GAD-7 scores go in a SOAP note?
Yes. Record them in Objective, with the previous score beside each one so the change is visible, and say what the change means in Assessment. If item 9 of the PHQ-9 is above 0, follow up in the session and record what you asked, what the client said and what you did.
What is the difference between SOAP and DAP notes?
DAP (Data, Assessment, Plan) keeps the client's account and your observations together in Data. SOAP splits them into Subjective and Objective. Assessment and Plan work the same way in both. SOAP suits sessions where the source of information matters; DAP gives a shorter note.
What is the difference between SOAP and BIRP notes?
BIRP (Behavior, Intervention, Response, Plan) gives your interventions and the client's response their own sections and has no separate Assessment. SOAP gives your clinical reading its own section and leaves you to choose where interventions go. The BIRP note examples show one session written both ways.
Can I use a SOAP note for an intake session?
You can, but most intakes need more than SOAP holds: history, a fuller mental status exam, diagnosis and the first treatment plan. Many therapists write a separate intake assessment and start SOAP notes at the second session.
How soon after a session should I write a SOAP note?
The same day when you can, while details are fresh. Your state board, payer contracts or practice policy may set a deadline. If you add a note late, mark it as a late entry with the date you wrote it.
Is a SOAP note a psychotherapy note under HIPAA?
No. HIPAA's definition of psychotherapy notes leaves out session times, modalities, test results, diagnosis, the treatment plan, symptoms and progress, which is what a SOAP note records. It is a progress note and part of the record. Whatever software stores your notes should sign a Business Associate Agreement with you; you can read TranqBay's Business Associate Agreement before you store anything.
Can clients read their SOAP notes?
Usually, yes. HIPAA gives clients a right to access their record, and progress notes are part of it; only psychotherapy notes kept separately are excluded (45 CFR 164.524). State law adds rules, for example for minors.
Do insurance companies require SOAP notes?
Payers generally don't require a particular format. They look for content: the date, start and end time, who attended, the problem being treated, what you did, how the client responded and a plan tied to treatment goals. Check your payer contracts for their own documentation rules.
Before your next session
Copy the template, write your next note with the checklist beside you and compare it with example 1. If your next note includes a risk screen, reread example 2 first.
If you also want booking, video sessions and session notes in one place, see how TranqBay works for private practice: you can look at the practice website templates and the booking steps your clients would go through. If you're deciding whether to join, this page explains how joining TranqBay works.
Sources
Regulations 2Associations 3suicidesafetyplan.com 1988 Lifeline 1
Laws and regulations2
- 145 CFR 164.501: definition of psychotherapy notes (eCFR)ecfr.govhttps://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.501
- 245 CFR 164.524: right of access to protected health information (eCFR)ecfr.govhttps://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524
Professional associations3
- 3National Association of Social Workers, Code of Ethics, standard 3.04 Client Recordssocialworkers.orghttps://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English/Social-Workers-Ethical-Responsibilities-in-Practice-Settings
- 4American Counseling Association, 2014 ACA Code of Ethics, standard A.1.bcounseling.orghttps://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf
- 5American Psychological Association, Record Keeping Guidelinesapa.orghttps://www.apa.org/practice/guidelines/record-keeping