8 Tips for Writing SOAP Notes for Mental Health

Information is useful and applicable when recorded. And if we talk about client progress in mental health treatment, recording becomes obligatory.

Why so?

Clinical notes really help to structure information about the client and his case, to notice some repetitive details, to put together a puzzle, let's say. Moreover, you can track efficiency and progress (and regression too).

A mental health progress note is a convenient tool for keeping track of patients' mental health. Clinicians use note-taking to track patient progress, to state patients' mental status and to provide patients with an effective and affordable treatment plan.

A plan section in a medical professional note is another reason. It's sometimes necessary to make adjustments to a treatment plan during or after a session. And when you attend a supervision-intervention, or transfer clients to another therapist, such records are very much in demand.

In contrast to different note-taking styles, SOAP progress notes will help you share patient assessment and plan with other health professionals in an organised manner.

After all, it's not for nothing that doctors always keep medical records? It probably makes sense.

In this article we've got you covered on:

• What is a SOAP format
• How SOAP notes compare to other documentation formats
• Tips for writing mental health SOAP notes
• A full SOAP note example for mental health
• Common mistakes to avoid
• Frequently asked questions, and more

What is a SOAP format?

The SOAP framework combines four core elements, in other words four specific letters in the acronym: Subjective, Objective, Assessment, and Plan.

These four elements, or stages, represent a sufficient structure of recording information for mental healthcare providers, capturing data about a client, his family and background, chief complaints, and certain aspects of the session.

The subjective part includes the client's condition, while the objective part provides some quantifiable data (tests, questionnaires, etc.). Assessment refers to the analysis of therapy sessions. And finally, the Planning stage contains treatment goals to be achieved.

Mental health SOAP notes are mainly used to record psychotherapy observations, but that's not the only benefit. This kind of patient note helps healthcare professionals to pass through all the workflow stages during patients' treatment, such as:

• Scheduling and rescheduling (including follow-ups)
• Check-in and examination
• Billing

Now we will consider all four stages and find out how to make the very most out of each one. Let's get started.

Subjective

The subjective section includes the client's condition. Here a clinician puts down information concerning the client's biggest complaint, and also adds other relevant information from the client. It's better to use direct quotes at this stage to be fully unbiased, because your priority now should be to seize a full picture of the symptoms that bother your client. Also, if it's a follow-up visit, you may write down some progress from the previous session.

For instance, you may include such quotes as:

Mary says, "I had a terrible headache."

Steven complains, "My nightmares never end."

After the direct speech, it's important to point out the elements of your further discussions about the given symptoms.

We think the type of information to avoid in the Subjective part needs to be noted.

Always try to avoid making assumptions, if they are not supported by the facts. In other words, in this point of note-taking, only information obtained from the client, his relatives, teachers, and friends can be attached, allowing you to get a sense of his mood, desires, and motivation. Don't make it up.

What to include in the Subjective section

The Subjective section is the starting point of the note, and it sets the tone for everything that follows. Beyond the chief complaint and direct quotes, you should also capture:

• History of present illness: A brief one or two sentence summary of the client's relevant background and what brought them in today.
• Current symptoms: Mood, sleep patterns, appetite changes, energy levels, and any recent life events that may be influencing the client's mental state.
• Follow-up context: If this is a return visit, note any changes since the last session, including whether assigned tasks or coping strategies were attempted.
• Collateral information: Where relevant, include observations from family members, teachers, or caregivers, clearly attributed to the source.

Keep this section factual and client-centered. The clinician's interpretation belongs in the Assessment section, not here.

Objective

The objective section, as you can see by its name, provides some quantifiable data (tests, questionnaires, etc.). Objective data contains the results of the physical exam, including the differential diagnosis, physical symptoms, mood, affect, body language and behavior of the patient.

Here, if compared with the objective part, you can use your personal observations about the client's behavior, for example:

• Is he nervous/talkative/twitching?
• What does his body language tell you? Is he cooperative or withdrawn?
• Is he able to participate in the session
• When and how do his responses occur?

Here you can also add the results of psychological tests, questionnaires and previous medical records if they are applicable.

For instance:

"Steven takes several seconds to answer my questions. The eye contact is very poor, he leans back, arms crossed."

Again, try to avoid value judgments, labels and words with negative connotations, such as stubborn, rude, or childish. Negative attitudes and judgments quickly take root in the mind of a person with psychological problems. You are here to help, not to judge.

Mental Status Exam (MSE) in the Objective section

One of the most important tools to document in the Objective section is the Mental Status Exam (MSE). The MSE gives clinicians a structured way to record observable aspects of a client's presentation during the session. Key areas the MSE covers include:

• Appearance and behavior: Grooming, eye contact, psychomotor activity
• Speech: Rate, volume, fluency
• Mood and affect: The client's self-reported emotional state versus the clinician's observed affect
• Thought process and content: Whether thinking is linear, tangential, or disorganised; presence of delusions or obsessions
• Perceptual disturbances: Hallucinations, illusions
• Cognition: Orientation to time, place and person; memory and concentration
• Insight and judgment: Does the client understand their condition and make reasonable decisions?

Including MSE findings in your Objective section strengthens both clinical accuracy and insurance compliance. It creates a documented snapshot of the client's functioning at that specific point in time.

Assessment

The assessment section refers to the analysis of therapy sessions. Its main goal is to combine the S and O sections, and interpret the professional information received during the session.

At this stage a healthcare professional implements the Diagnostic and Statistical Manual of mental disorders (DSM), meaning that he identifies its criteria, vital signs, themes and individual patterns of a patient's mental status.

Put another way, here you can use specific psychiatric and psychological terms and abbreviations, such as abundance of guilt, anxiety, moderate depression, anxious distress, melancholy, ECT, TMS, VNS, persistent depressive disorder and other. You can also share information about whether a client meets the criteria for generalized anxiety disorder, known as GAD, as a common mental health problem.

Furthermore, you should avoid repeating your previous statements in the S. O. sections. Progress and regression are reported in the assessment section.

Planning

In the planning stage, there are treatment goals that need to be met. This is the plan for a client, so he can see how to reach the long term goals you've set together.

Here your task is to focus on the following:

• Steps for the follow-up appointments
• The symptoms to pay attention to next time
• Treatment plan assessment (or reassessment).

For example, it can be used to add nutrition consultation, to run additional analyses, or even to change a lifestyle plan.

Remember to set realistic and measurable goals, so that a client can achieve them before the next session. Reaching small goals within a larger plan has a positive effect on the entire treatment.

Needless to say, SOAP note templates facilitate next sessions, combining objective and subjective information for better therapy notes.

In addition, they impact the patient journey from the moment they develop symptoms and schedule a doctor's appointment to the moment they complete medical treatment. If you know the clinical reasoning behind why, when and what you do to cure someone, then it is always an advantage.

SOAP Notes vs Other Documentation Formats

Mental health clinicians have several note-taking formats to choose from. Understanding how SOAP notes compare to the alternatives helps you decide when each format is most appropriate.

When should you use a SOAP note in mental health? SOAP notes are the preferred choice when documentation needs to support insurance billing, coordinate care across multiple providers, or meet regulatory standards. Their structured separation of subjective and objective data makes them particularly valuable in psychiatry and integrated care settings.

DAP notes work well for solo practitioners who need speed. BIRP notes shine when the primary goal is tracking behavioural progress across sessions. For most clinical environments in 2026, SOAP remains the most widely recognised and compliance-ready format.

Full SOAP Note Example for Mental Health

To make the four sections more concrete, here is a worked example using a fictional client presenting with symptoms of anxiety and depression.

Client: Steven M., 34-year-old male Session type: Individual psychotherapy, 50 minutes Date: Follow-up session, week 6

S (Subjective)

Steven reports feeling "exhausted all the time" and states that his sleep has worsened since the last session. He says, "I wake up at 3am and can't get back to sleep. My mind just won't stop." He reports low motivation and difficulty concentrating at work. He denies any suicidal ideation or intent. His partner has noted that he has been more irritable at home over the past two weeks.

O (Objective)

Steven arrived on time, appropriately dressed, and cooperative throughout the session. Eye contact was minimal during the first half of the session and improved slightly as the session progressed. Speech was slow and quiet. Affect appeared flat and constricted. He completed the PHQ-9 at session start, scoring 14 (moderate depression), up from 11 at the previous session. He engaged in cognitive restructuring exercises but required significant prompting.

A (Assessment)

Steven continues to meet criteria for Major Depressive Disorder (MDD), moderate severity, with associated anxious distress. The increase in his PHQ-9 score and worsened sleep are consistent with a mild deterioration in functioning over the past two weeks. The stressors appear to be occupational in nature. Current coping strategies are partially effective but require reinforcement. Differential consideration of a comorbid generalised anxiety disorder (GAD) remains active.

P (Plan)

1. Continue weekly individual psychotherapy with a focus on cognitive behavioural techniques for sleep and mood regulation.
2. Introduce sleep hygiene psychoeducation and assign a sleep diary before the next session.
3. Discuss referral to prescribing psychiatrist for medication review given worsening PHQ-9 score.
4. Review occupational stressors in the next session and explore boundary-setting strategies.
5. Reassess PHQ-9 at next session to monitor trajectory.
6. Follow-up appointment scheduled in one week.

This example demonstrates how each section builds on the previous one. The Subjective captures what the client reports, the Objective records what the clinician observes and measures, the Assessment synthesises both into a clinical picture, and the Plan translates that picture into concrete next steps.

Common Mistakes to Avoid in Mental Health SOAP Notes

Even experienced clinicians make documentation errors that can create problems during audits, insurance reviews, or care transitions. Here are the most common pitfalls and how to avoid them.

Mixing subjective and objective content. One of the most frequent errors is placing clinical observations in the Subjective section, or client quotes in the Objective section. Keep these distinct. The client's words belong in S. Your observations belong in O.

Using vague or ambiguous language. Words like "seemed," "appeared to be doing better," or "may have" weaken your documentation. Be specific. Instead of "client seemed anxious," write "client reported feeling anxious and displayed rapid speech and fidgeting throughout the session."

Repeating information across sections. The Assessment section should synthesise and interpret, not restate what you already wrote in S and O. If you find yourself copying sentences between sections, that is a sign the structure needs tightening.

Omitting risk assessments. Every session note should document whether suicidal ideation, self-harm, or harm to others was assessed, even if the answer is negative. Omitting this creates a significant legal and clinical gap.

Failing to update the plan. A plan that carries over unchanged session after session suggests the clinician is not responding to the client's evolving needs. The Plan section should reflect what is actually happening in treatment right now.

Using stigmatising language. As noted in the Objective section guidance above, avoid labels like "manipulative," "non-compliant," or "difficult." These terms reflect judgment rather than clinical observation and can negatively colour future providers' perceptions of the client.

8 tips for writing mental health SOAP notes

A mental health professional has a lot of responsibilities during and after the session. Sometimes making up a workable soap note format can be a challenge. To make things easier for you, we've summarised the top 8 tips to focus on when writing your notes:

1. Keep in mind avoiding moral and value judgments
2. When you use direct speech, make sure that you cite the exact words
3. Avoid any uncertainty, for example, such words as "may", "seem", "appear"
4. Always write legibly, without incomprehensible abbreviations
5. Use special language and professional jargon
6. Mind your grammar and spelling, don't forget to proofread with a grammar checker
7. If you still have any doubt in writing the SOAP notes then use AI tools such as a free sentence improver. This tool helps improve the overall quality of your notes while saving you time.
8. Imagine that you are about to defend the content of your note. Write it accordingly.

And here is one extra tip for you.

If you are working with patients remotely, via telehealth or telemedicine, SOAP note examples are also required. As a result, switching from paper to EHR ensures proper security of your notes that you do not want to lose.

You should include:

• Date and time of the appointment
• Time of the follow-up visit
• Mental status
• Type of connection (telephone, video conference, chat)
• Location of the medical provider (home/office)

Digital SOAP notes can be filled directly into the patient's medical card during or after the consultation, thanks to the embedded mental health progress note templates. This option encourages efficiency, coherence, and care consistency.

Frequently Asked Questions About SOAP Notes in Mental Health

What is a SOAP note in mental health?

A SOAP note in mental health is a structured documentation format used by clinicians to record session information in four sections: Subjective, Objective, Assessment, and Plan. It provides a consistent framework that supports clinical reasoning, care continuity, and compliance with insurance and legal requirements.

How long should a mental health SOAP note be?

Most mental health SOAP notes are two to four paragraphs in total, though length will vary depending on session complexity. The goal is to be thorough without being repetitive. Each section should contain only the information relevant to that part of the framework.

Can SOAP notes be used for telehealth sessions?

Yes. SOAP notes are equally applicable to telehealth and in-person sessions. For remote sessions, you should also document the type of connection used (video, phone, or chat), the client's location, and the provider's location at the time of the session. This information is often required for insurance billing purposes.

How do SOAP notes support insurance billing?

Insurers expect to see documentation that justifies the services rendered. A well-completed SOAP note demonstrates the client's presenting problem, the clinician's assessment, and the rationale for the chosen treatment approach. Missing or vague documentation is one of the most common reasons claims are denied or flagged for audit.

What is the difference between a SOAP note and a progress note?

A progress note is a broad term for any written record of a clinical session. A SOAP note is a specific type of progress note that follows the Subjective, Objective, Assessment, Plan structure. Not all progress notes follow the SOAP format, but all SOAP notes are a form of progress note.

How often should SOAP notes be completed?

SOAP notes should be completed after every clinical session. Most professional and regulatory standards require that notes be finalised within 24 to 48 hours of the session taking place. Delaying documentation increases the risk of inaccuracies and can create compliance problems.