How to write SOAP notes for a therapy session, with a template

By Sadique Ali, Glyphora, maker of Psyledger7 September 20268 min read

A session note has two readers. The first is you, a week later, trying to remember where the last session ended. The second is a stranger: a supervisor, a court, a regulator, a client exercising their right to see their record, or a colleague who takes over your caseload when you cannot. A good note serves both, and the SOAP structure is the simplest way to write one that does.

This guide is for clinical and counselling psychologists and counsellors in private practice in India. It covers what belongs in each section, a worked example, the mistakes that make notes useless or dangerous, and the practical questions of timing, retention and locking. A copy-and-paste template is at the end.

What SOAP is, and why it survived

SOAP stands for Subjective, Objective, Assessment and Plan. It came out of medicine in the 1960s as a way to make a record readable by whoever picked up the chart next. It survived in mental health because it forces a separation that matters: what the client reported, what you observed, what you make of it, and what happens next. Notes that blur those four are the ones that read badly in a hearing.

The alternative many therapists prefer is DAP, which folds Subjective and Objective into a single Data section. DAP is shorter and fine for routine sessions; SOAP is better when you need to show your reasoning, which is exactly when a note is later read. Whichever you choose, choose one per practice and use it every time.

The four sections

S: Subjective

What the client said, in their words or a faithful paraphrase. Presenting concern for this session, changes since last time, their own rating of mood or symptoms, anything they volunteered about sleep, appetite, work, relationships, medication, substances. Include what they did with last session's plan. If they reported thoughts of self-harm, this is where the report goes, as reported.

Keep it to what is clinically relevant. A client's account of a film they saw is not subjective data unless it bears on the work. Quote only when the exact words matter, for instance a description of suicidal ideation, and mark the quote.

O: Objective

What you observed: appearance, behaviour, affect and its congruence with reported mood, speech, thought process, orientation, and anything measured, such as a PHQ-9 or GAD-7 score from this week. Attendance and punctuality belong here. So does the modality, in person or online, and the duration.

The test for this section: could another clinician in the room have written the same sentence? "Client seemed anxious" fails; "Fidgeted with sleeve throughout, spoke rapidly, described own mood as 7 out of 10 for anxiety" passes.

A: Assessment

Your clinical judgement, briefly. How the presentation fits the working formulation, progress against goals, response to the intervention used, and, every session, a risk statement. Three words are enough when there is no risk: "No current risk." When there is, say what you asked, what the client said, and what protective factors exist.

This is the section a reader most needs and the one most often left empty. If you are unsure, write that you are unsure and what would resolve it.

P: Plan

What happens next. The intervention planned for the next session, any between-session task, referrals, letters to write, an assessment to send, a date to review the formulation, and the next appointment. If the plan changed from last time, say why in one line.

A worked example

The client is invented. Names and details are placeholders, not a real person.

Date and time: 3 June, 10:00 to 10:50, in person. Session 6.

S: Reports a "moderately better" week. Sleep onset now about 40 minutes, down from roughly 90, since starting the wind-down routine agreed last session. Continues to notice anticipatory worry before Monday team reviews. Rates overall anxiety at 5 out of 10 this week, down from 7. No change in appetite. Completed the thought record on four of seven days.

O: On time, well groomed, cooperative. Mood euthymic with reactive, congruent affect. Speech normal in rate and rhythm. Thought process linear and goal directed. No psychomotor agitation. GAD-7 this week 9, from 12 at intake.

A: Generalised anxiety presentation continuing to respond to CBT. Sleep-hygiene gains support behavioural activation. Anticipatory worry around performance remains the primary maintaining factor. No current risk; denies self-harm thoughts on direct enquiry.

P: Next session: cognitive restructuring on performance predictions using this week's thought records. Between sessions: continue wind-down routine; add one scheduled worry period of 15 minutes. Send GAD-7 link before session 8 for a four-week trend. Review formulation at session 8. Next appointment 10 June, 10:00.

Notice what the example does not do. It does not repeat the whole history. It does not record the client's opinion of a colleague by name. It does not diagnose in passing. It gives a reader in six months exactly what they need in about 200 words.

What to leave out

• Third parties by name. "Conflict with her manager" is enough; the manager's name is not your client's data to give away and it is someone else's to protect.
• Verbatim transcripts. A note is a record of the work, not of the conversation.
• Your private reactions. Countertransference belongs in supervision notes, which are yours, not in the client's record, which is theirs to request.
• Speculation dressed as fact. "Probably borderline" in an Assessment section is a sentence you will be asked about. Write what you observed and what you hypothesise, and label the hypothesis.
• Anything you would not want the client to read. Under India's data protection law a client can ask for a summary of what you hold. Write every note as though they will.

Timing, signing and changing your mind

Write the note the same day, before the next client if you can. Recall degrades fast and the law of records is unkind to notes written a week later. Many practices set a rule of 24 hours and treat a note left unwritten past that as an incident.

Sign the note when it is complete and then treat it as fixed. If you later realise something was wrong or missing, do not edit the original; add a dated addendum that says what you are adding and why. A record that shows an edit after a complaint was made is worse than a record with an honest addendum, and a system that lets a signed note be silently rewritten is a system that cannot protect you.

Risk, every time

Put a risk line in every note, even when the answer is "none". The line that matters most in any later review is the one that shows you asked. When a client reports ideation, record what they said, what you asked about plan, means and intent, the protective factors, the safety plan agreed, and who else you informed and when. If an assessment such as the PHQ-9 raised its self-harm item, record that you saw it and what you did.

How long to keep notes

India has no single statutory retention period for psychologists' records. The Rehabilitation Council of India's conduct norms expect records to be maintained; tax law fixes periods for invoices; the data protection law expects you to keep personal data only as long as the purpose requires and to have a written reason for the period you choose. A common and defensible policy is seven years from the end of care for clinical notes and assessments, longer for a minor, counted from adulthood, and eight years for financial records. Write your periods down, apply them consistently, and confirm them with your regulator or counsel.

Notes for a team

In a clinic, session notes should be readable only by the treating clinician. The owner has administrative authority over the practice, not clinical authority over another therapist's clients, and a supervisor should see a note only through an explicit, recorded share with the client's consent. Front-desk staff should never see clinical content at all. If your system cannot enforce that, the policy is only a wish.

The template

Copy this into your notes system, or onto paper, and use it for every session.

Date, time, duration, modality, session number

S, Subjective: presenting concern this session; changes since last; client's own ratings; sleep, appetite, work, relationships, medication, substances as relevant; what they did with the last plan; any reported risk, as reported.

O, Objective: appearance, behaviour, affect, speech, thought process, orientation; measured scores; attendance.

A, Assessment: fit with formulation; progress against goals; response to intervention; risk statement, every time.

P, Plan: next intervention; between-session task; referrals or letters; assessments to send; review date; next appointment.

Signed: name, registration number, date and time.

Addenda: dated, signed, never overwriting the original.

Where software helps

The structure above can live in a notebook. What a notebook cannot do is lock a note when you sign it, keep a dated addendum trail, hide a note from everyone but you, log who opened it, and put this week's GAD-7 beside the note as you write. Psyledger does those things, with SOAP, DAP, intake, progress and treatment-plan templates and a risk field that will not let you skip the question. But the discipline of writing a clear note the same day is yours, and it is the part that matters.

This guide describes documentation practice in general terms. Retention periods and disclosure duties vary; confirm yours with your regulator or counsel.