SOAP Notes for Therapy: Format, Examples and Template

• A SOAP note records a therapy session under four headings: Subjective (what the client reports), Objective (what you observe), Assessment (your clinical interpretation and progress toward goals) and Plan (next steps).¹
• Under HIPAA, a SOAP note in the chart is a progress note. The extra protection for psychotherapy notes covers only separate notes that leave out session times, modalities and summaries of diagnosis, treatment plan, symptoms and progress.²

A billed therapy session ends with a progress note in the client’s chart. SOAP is a widely used structure for that note. It splits the session into what the client told you, what you observed, how you read it clinically and what happens next. Medicare reviewers and other payers read the same note to check the time billed and the medical necessity of care. For a tool that drafts the note for you, see our Upheal pricing guide. HIPAA gives psychotherapy notes kept apart from the chart more protection than progress notes.

This article is for information only and is not medical or legal advice. Documentation rules vary by state, license and payer. Our therapy progress notes cheat sheet compares SOAP with DAP, BIRP, GIRP and PIRP.

Compare SimplePractice’s SOAP note templates

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What goes in each section of a therapy SOAP note

Physician Lawrence Weed developed the SOAP note as part of the problem-oriented medical record. His paper “Medical records that guide and teach” ran in the New England Journal of Medicine in March 1968.¹ The table shows what each heading holds in a therapy note.

StatPearls flags a common mistake: symptoms are the client’s descriptions and belong under Subjective, while signs are observed findings and belong under Objective.¹ “Client says she feels hopeless” goes in S. “Flat affect, minimal eye contact” goes in O.

StatPearls also notes that SOAP has a limited ability to show change over time, so tie each Assessment back to treatment plan goals.

Therapy notes samples in SOAP format

The three sample therapy session notes below are fictional composites written for this article. The clients and details are invented and come from no client record. The notes are not clinical guidance for any case.

Example 1: Individual session for work-related anxiety

Fictional client A, adult. Individual video session, 2:00 pm to 2:50 pm (50 minutes).

• S: Client reported three episodes of racing heart and worry before team meetings this week, down from five the week before. She practiced the breathing exercise on four of seven days. She denied thoughts of harming herself or others when asked.
• O: On time, alert and casually dressed. Tapped a pen while describing an upcoming review. Affect anxious and congruent with content.
• A: Progress on goal 1 (reduce anticipatory anxiety at work), with fewer episodes and steady home practice. She still avoids speaking in meetings. Interventions: cognitive restructuring of the thought “everyone will see I’m incompetent” and guided breathing. She named one alternative thought. No risk indicators identified.
• P: Continue weekly sessions. Homework: thought record before two meetings. Review goal 1 at session 8.

Example 2: Individual session for low mood

Fictional client B, adult. Individual in-person session, 10:00 am to 10:45 am (45 minutes).

• S: Client reported low mood on most days since losing his job six weeks ago, less interest in cooking and about 10 hours of sleep a night. He completed one of three planned activities. He denied suicidal thoughts when asked.
• O: Arrived five minutes late. Affect flat in the first half, brighter when discussing his sister’s visit. Speech soft with long pauses.
• A: Mood symptoms continue, with a small gain in activity. Behavioral activation reviewed; client identified mornings as the point where plans fall apart and chose two activities before noon. Slow progress on goal 2 (increase daily activity).
• P: Continue weekly sessions. Homework: two morning activities and a daily mood rating. Client agreed to raise his sleep with his primary care doctor. Safety plan and the 988 Suicide & Crisis Lifeline reviewed.

Example 3: Couples session about recurring conflict

Fictional clients C and D, adult couple. Joint video session, 6:00 pm to 6:55 pm (55 minutes).

• S: Both partners reported two arguments about spending this week. Partner D said he feels criticized and leaves the room. The agreed time-out cue worked once.
• O: Partners took turns speaking with prompting. Voices rose once during the budget discussion, and both de-escalated after the therapist called a pause.
• A: The time-out skill supports goal 1 (reduce escalation during conflict). A pursue-and-withdraw pattern around money is still active. Interventions: speaker-listener exercise and a review of the conflict cycle; both partners paraphrased each other accurately. Neither partner reported safety concerns.
• P: Continue weekly joint sessions. Homework: one 15-minute budget talk in speaker-listener format.

A therapy notes template you can copy

This therapy SOAP notes template doubles as a therapy progress notes template. It follows the order above and adds the fields payers ask for. Delete the prompts you don’t need.

• Client name / ID:
• Date of service:
• Session type (individual, couple, family, group; video or in person):
• Start time:
• Stop time:
• Total minutes:
• Clinician name and credentials:

S – SUBJECTIVE

• Client report since last session:
• Homework completed:
• Risk screen (as reported):

O – OBJECTIVE

• Appearance, behavior, affect, speech:
• Measures given (if any):

A – ASSESSMENT

• Interventions used and client response:
• Progress toward treatment plan goals:
• Barriers and risk:
• Medical necessity for continued care:

P – PLAN

• Next session focus and homework:
• Referrals or coordination:
• Frequency and next appointment:

• Signature:
• Date signed:

How to write therapy progress notes

Write the note as close to the session as you can. The CMS Program Integrity Manual expects services to be documented at the time they’re rendered. Late entries must show their date and author clearly.³ California’s Medi-Cal behavioral health rules allow three business days, or 24 hours for crisis services.⁴ The ACA and NASW codes of ethics both call for timely documentation.

Keep the language objective: “tearful when discussing her father” tells a reviewer more than “very emotional.” The NASW code asks for accurate records that hold only information directly relevant to the services. SimplePractice’s own guidance advises leaving out subjective opinions and irrelevant details.

A few habits make notes faster and easier to defend:

• Name the interventions you used and how the client responded, since payers look for both.
• Mark amendments with the date and your name instead of overwriting the original entry.
• Start from the previous note. Clinicians often report that starting from the previous note and using checkbox intervention lists bring note time down to a few minutes.

Therapists most often struggle with the Assessment. They tend to name progress toward goals, barriers, risk and medical necessity as what insurers look for there.

What payers expect in a psychotherapy note

Psychotherapy CPT codes are time-based. Medicare billing article A57520 requires start and stop times or total time for 90832, 90834 and 90837. The time bands are 16 to 37 minutes, 38 to 52 minutes and 53 minutes or more.⁵ Sessions under 16 minutes aren’t reported, and E/M time doesn’t count toward psychotherapy time. Our guide to CPT codes for psychotherapy covers each code.

CGS’s coverage policy L34353 says the record must show the time spent and the therapeutic maneuvers used. The policy also requires a periodic summary of goals, progress and an updated treatment plan.⁶ Palmetto’s policy asks for a trend of improvement or regression even when one session shows little change.

See SimplePractice’s progress note templates

Progress notes vs psychotherapy notes under HIPAA

A SOAP note filed in the client’s chart is a progress note, and HIPAA treats it like other protected health information. Under 45 CFR 164.501, psychotherapy notes are a mental health professional’s notes documenting or analyzing the contents of a counseling session, kept separate from the rest of the medical record. The definition excludes medication prescription and monitoring, session start and stop times, the modalities and frequencies of treatment, clinical test results, and any summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date.²

The separation affects disclosure, client access and audits:

• Disclosure. Disclosing psychotherapy notes generally needs the client’s authorization, even to another treating provider, with exceptions such as mandatory abuse reporting and duty-to-warn situations.⁷
• Client access. The right of access in 45 CFR 164.524 excludes psychotherapy notes, and that denial can’t be reviewed. Progress notes are covered, and you must act on a request within 30 days, with one extension of up to 30 more.⁸ A proposed cut to 15 days hadn’t been finalized as of September 28, 2026.
• Audits. CMS says merging excluded information into a psychotherapy note doesn’t make it protected, and Medicare reviewers may not request psychotherapy notes. You still have to show the service was medically necessary, or the claim is denied.³

SimplePractice keeps psychotherapy notes in their own section, apart from progress notes, on all three plans.

How long to keep therapy records

HIPAA doesn’t set a retention period for clinical records. HHS says state laws generally govern how long records are kept, while HIPAA requires safeguards for as long as you keep them.⁹ The six-year rule in 45 CFR 164.530(j) applies to compliance documentation such as written policies and procedures. The clinical chart falls outside it.¹⁰

In California, psychologists keep records at least seven years from discharge, or seven years from a minor’s 18th birthday. The APA’s 2007 record keeping guidelines were archived in 2019. They suggested seven years after the last service for adults or three years after a minor comes of age, whichever is later.¹¹

DAP, BIRP, GIRP and PIE notes

SOAP is one of several progress note formats. SimplePractice’s template library includes DAP and SOAP notes, and Practice Better supports SOAP, ADIME, DAP, BIRP and custom formats.

SOAP templates and AI note-takers in EHRs

SimplePractice, Jane and Practice Better all offer SOAP note templates, and each EHR below sells an AI tool that drafts notes. Prices are as of September 2026.

SimplePractice Note Taker

SimplePractice plans cost $49, $79 or $99 a month, and progress note templates are customizable on the $79 Essential and $99 Plus plans. Note Taker transcribes SimplePractice Telehealth sessions live or works from an uploaded file or dictation, and it doesn’t store a session recording. It drafts the note from the transcript and the client’s previous note, following that note’s format. You must review and edit the draft before saving. Essential plus Note Taker is $114 a month for a solo clinician.

The transcript stays available for up to seven days or until you sign and lock the note, whichever comes first. If you enable Note Taker on or after June 17, 2026, you’re opted in by default to SimplePractice keeping de-identified transcripts to improve its AI features. You can opt out at any time.¹²12 Transcript retention is the main privacy worry therapists raise about AI scribes this year.

Consent is your practice’s responsibility. SimplePractice points to state law and notes that some states require every party’s consent to record a session. It also offers a consent form for AI use. Illinois’s Wellness and Oversight for Psychological Resources Act was signed in August 2025. It allows AI note support only with the client’s written consent when sessions are recorded or transcribed. Our SimplePractice review covers the rest of the platform.

Jane, Practice Better and Healthie

Jane‘s AI Scribe can start from a SOAP note and keeps recordings out of the legal medical record. Practice Better prices its AI assistant by the hour, and Healthie adds behavioral health charting templates. Our SimplePractice alternatives guide compares them.

See SimplePractice plans and Note Taker