SOAP notes are a standardized method for documenting patient interactions in clinical settings. The acronym stands for:
- Subjective – What the patient says
- Objective – What the therapist observes or measures
- Assessment – The therapist’s professional interpretation
- Plan – Next steps in treatment
Originally developed for physicians, SOAP notes have become essential in therapy disciplines like speech, occupational, behavioral, and physical therapy.
Why SOAP notes matter in therapy
Effective SOAP notes do more than meet documentation requirements. They:
- Support continuity of care between different providers
- Track patient progress over time
- Ensure compliance with insurance and legal standards
- Help therapists reflect on the effectiveness of treatment
For busy practices, consistent SOAP notes also make internal communication smoother and reduce errors or misunderstandings.
How to write SOAP notes: a step-by-step breakdown
1. Subjective
Capture what the patient reports in their own words. This might include:
- “I felt more anxious this week.”
- “My child refused to use the speech card.”
Stick to quotes when possible and avoid interpretation in this section.
2. Objective
Include measurable observations and clinician findings:
- “Client completed 3 out of 5 articulation tasks with 80% accuracy.”
- “Observed difficulty maintaining eye contact during session.”
This is the space for clinical data, scores, or therapist observations.
3. Assessment
Analyze the subjective and objective data to make a professional judgment:
- “Client is making steady progress with expressive language goals.”
- “Symptoms suggest moderate improvement in self-regulation.”
This is the most analytical part of the note and often where clinical insight shines.
4. Plan
Outline what comes next:
- “Continue with current plan; increase session time to 45 minutes.”
- “Introduce new behavior reinforcement strategy next session.”
This section ensures accountability and continuity of care.
SOAP note examples for therapy sessions
Speech therapy example
- S: “I practiced my S sounds with my dad this week.”
- O: Client produced /s/ in initial position in 7 out of 10 words.
- A: Client is generalizing skills from therapy to home environment.
- P: Continue current plan; introduce multisyllabic words with /s/.
ABA therapy example
- S: Parent reported fewer tantrums at home.
- O: Client independently used picture exchange in 4 of 5 trials.
- A: Functional communication is increasing with consistency.
- P: Maintain PECS intervention; train caregiver on reinforcement timing.
Occupational therapy example
- S: “My hand gets tired quickly when I write.”
- O: Fine motor tasks completed with mild fatigue after 10 minutes.
- A: Endurance remains limited; grasp is improving.
- P: Introduce handwriting breaks and use pencil grips next week.
FAQs about SOAP notes
1. Do all therapy clinics need to use SOAP notes?
While not legally required in all settings, SOAP notes are widely accepted and recommended for accurate and compliant documentation.
2. Can SOAP notes be used for group sessions?
Yes. Just ensure each individual’s progress is noted separately to maintain clarity and confidentiality.
3. What’s the difference between SOAP notes and progress notes?
SOAP notes are a type of progress note, but more structured. Some clinics use both depending on the session type.
4. Are there digital tools to help with SOAP notes?
Absolutely. Many therapy practices use EHRs or AI-powered assistants to streamline the process, reduce errors, and save time.
5. How long should a SOAP note be?
Brevity is key—aim for 1–2 concise sentences per section unless a session was particularly complex.
Final thoughts
SOAP notes aren’t just a formality—they’re a critical part of delivering thoughtful, accountable care in any therapy setting. With a little structure and practice, writing high-quality notes can become second nature.
Want to make clinical documentation easier for your whole team? Start by applying the tips and examples above—and keep evolving your workflow.
