Which of the following would be included in the objective part of the SOAP method?

SOAP notes—originally referred to as a problem-oriented medical record (POMR)—was created in the 1950s by physician Lawrence Weed to standardize the method of documentation that would simplify treatment plans. Today, SOAP notes have evolved and are used by many practitioners in the health and wellness field to record a patient or client interaction.

What is a SOAP note?

SOAP note stands for Subjective, Objective, Assessment, and Plan. These notes are a form of written documentation that professionals in the health and wellness industry use to record a patient or client interaction. Since all SOAP notes follow the same structure, all your information is clearly laid out. That way, it’s easy for you and any other providers to easily read the note at a later date and immediately know what’s going on in a client’s treatment plan.

In this article, we’ll go over how to write a SOAP note, what to include in each section, and how easy it is to use SOAP notes with your EHR.

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Why you should use SOAP notes

You should use SOAP notes for your practice because they’re a way of standardized note-taking. SOAP notes allow practitioners in the health and wellness industry to document their findings in an objective way, and in a format that is easily recognizable by other practitioners across other industries. Keeping these notes formatted and structured in a specific way ensures that practitioners don’t forget to include an important section or become unorganized. In addition, SOAP notes are an essential piece of information that helps inform the practitioner about the ongoing health status of their client.

How to write SOAP notes

When you write SOAP notes, you follow a specific structure, which hits each letter of the SOAP acronym. This standardized structure ensures that you’re organizing your notes precisely and helps you assess, diagnose, and treat clients using the correct information. This format is also easily recognizable by healthcare providers in other specialities—making it easy to coordinate care for your clients with other practitioners.

What should be in a SOAP note?

What should be in a SOAP note will depend on your speciality, who your client is, and what you’re working on during your sessions together. We’ve broken down the order of how you should write a SOAP note, and what should (and shouldn’t) be included.

S: Subjective

This section is for subjective reporting of your clients. It can include their mood, their reported symptoms, their efforts since your last meeting to implement your homework or recommendations, or any questions they have.

Start with the client’s history that has any relevant behavior. This can include:

• Medical and mental history
• Medications
• Day-to-day routines
• Complaints and/or problems

This section should not include:

• Statements without supporting evidence
• Unsourced opinions

Make sure any opinions or observations you include in the section are attributed to who said them, whether it’s yourself, your client, a parent, etc. Since this is a subjective section, you don’t want to pass off any of this information as fact.

O: Objective

This part of your SOAP note should be made up of quantitative, factual, and measurable data. This might include specific interventions used in the session, or measurable outcomes, like test scores, percentages of completion for goals worked on, etc. Examples include:

• Client’s mental status
• Physical and psychological observations
• Relevant reports, like medical records or information from from other specialists
• Client behavior: how did they present themselves? Was there nervous talking or lack of eye contact?

This section should not include:

• Personal judgements
• General statements that don’t have supporting evidence
• Assumptions pertaining to their behavior
• Words or phrases that have negative connotations

Overall, this section should avoid general statements that don’t have supporting data. If you are discussing specific clinical interventions, why you chose that intervention and how it relates to the overall treatment plan should be made clear.

A: Assessment

Combine the S and O sections to create your official 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
• DSM criteria/Therapeutic Model to identify the issues and treatment

This section should not include:

• Repetitive statements from the previous sections

Make sure you don’t just repeat what you wrote in the S and O sections of your SOAP note. Take a step back and review your client’s progression (or regression) over time, and assess what factors may have contributed to this change.

P: Plan

The last part of your SOAP note should outline your plan for next steps, based on the problems you’ve identified. In this section, state any and all activities, objectives, or reinforcements that you’re changing. This can include:

• Progression or regression the client has had
• Next steps for upcoming sessions
• How you’ll implement the treatment and next steps
• Any physical, mental, or nutritional elements that could have an effect

This section should not include:

• Rewriting your entire treatment plan
• Goals that are immeasurable or unrealistic

If your client isn’t meeting the goals you’ve set, you don’t need to entirely change the treatment plan in this section. Rather, this section is for tracking progress, and making any necessary adjustments to the existing plan to help your client meet their goals.

4 tips for writing SOAP notes

Here are some general tips to keep in mind when writing your SOAP notes.

• Don’t include unsourced opinions or statements you can’t back up with facts.
• In general, avoid verbs like “discussed” or “explored,” when writing your objective section, as it’s not clear what the purpose of such discussion or exploration would be.
• Don’t repeat content from a previous section. Make sure each section has unique content.
• Don’t rewrite your whole treatment plan each time. Simply make adjustments where needed.

SOAP notes therapy examples

To illustrate how each of the parts of the SOAP notes work, here are some SOAP notes examples. 

SOAP note example for social workers

S: Subjective

Client reports feeling more anxious this week. She said she felt more jittery and on-edge, and reports having more anxious thoughts that were harder to control. 

O: Objective

During the session the client was fidgety, wringing her hands and speaking quickly. She appeared to have difficulty concentrating and asked me to repeat questions multiple times before responding. Client described a fear of losing her job and her housing, though admitted she didn’t have any evidence those events were imminent. 

A: Assessment

Based on the client’s report and observations during the session, the client’s anxiety has increased, but continues to meet criteria for GAD. 

P: Plan 

Recommended client see a primary care physician to rule out any thyroid or other medical condition. Client will continue coming to therapy once a week for the foreseeable future to treat anxiety through CBT, and recommended client try some meditation and other mindfulness techniques at home in between sessions. 

SOAP note example for SLPs

S: Subjective 

The client reports increased vocal demands since the last meeting, due to additional meetings at work. She notes her colleagues commented “your voice is back!” after her last work presentation, but that she still experiences intermittent vocal fatigue during social events. She reports she has been incorporating her semi occluded vocal tract straw (SOVT) routine 3 times a day for 5 minutes. 

O: Objective 

Led the client through SOVT exercises with a straw in water. Client independently achieved optimal voicing in 5/5 opportunities. Introduced conversational training therapy (CTT) where client differentiated between her “husky” voice and her “presenter” voice in 5/5 opportunities. Practiced functional phrases where client achieved “presenter” voice in 8/10 opportunities with moderate visual cues. The client’s vocal effort using CTT was 4/10.  

A: Assessment 

The client met goals of optimal voicing to meet vocational demands, as evidenced by an improvement from vocal effort of 7/10 (“somewhat hard”) to 4/10 (“somewhat easy.”) She is pressing toward carryover of SOVT strategies to meet social demands.

P: Plan

Continue the current plan of care. Target optimal voicing in functional environments with CTT techniques. Introduce additional compensatory strategies to manage vocal load across vocational and social settings. 

How to use SOAP notes with your EHR

It’s easy to use SOAP notes with your EHR. Most top-rated practice management softwares should have SOAP notes and other note-taking templates built right into the platform, so it’s easy to access your notes and fill it out after each session.

If your EHR doesn’t have built-in SOAP notes, you can download a SOAP note template to keep on hand, or make your own following the guidelines we provided above. Remember, SOAP notes are meant to document your findings in a way that’s easy to refer back to, so you should use the format that makes the most sense for your practice.

If you’ve been considering switching to a fully integrated, HIPAA-compliant practice management software, SimplePractice gives you everything you need to streamline your note-taking process. You can pull a SOAP note template from our robust template library, use our load previous note feature to easily update your notes each session, and send follow-up information about your sessions to your clients through the client portal. Plus, SimplePractice is consistently rated as one of the best software for therapists, speech-language pathologists, occupational therapists, and other practitioners in the health and wellness industry.

Related reading

• How to Write Therapy Progress Notes
• How to Write DAP Notes
• How to Write BIRP Notes

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