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A SOAP note is a progress note format that organizes a clinical encounter into four sections: Subjective, Objective, Assessment, and Plan. Therapists, psychologists, and integrated care teams use SOAP notes to document sessions in a structure that other providers, payers, and auditors can read quickly. A typical therapy SOAP note runs 150 to 350 words.
Therapists, psychologists, counselors, integrated behavioral health teams
Treating clinician, care team, supervisors, payers, auditors
150 to 350 words · 10 to 20 minutes by hand (clinical team estimate)
Structured progress note (compare: DAP, BIRP, PIE)
After each individual, group, or telehealth session
A documentation convention, not a mandated form; sits on top of HIPAA and payer requirements
SOAP stands for Subjective, Objective, Assessment, Plan. The format grew out of Lawrence Weed's problem-oriented medical record framework, introduced in 1968, and spread from medical charting into behavioral health because primary care teams and payers already know how to read it. Some clinicians also call it a therapy SOAP note or counseling SOAP note.
Two clarifications save a lot of confusion. First, no law requires the SOAP format: HIPAA, state boards, and payers require that records be accurate, complete, and appropriate to the service, and SOAP is simply one accepted way to get there. Medicare's Program Integrity Manual states that progress notes "may be in any form or format." Second, a SOAP note is a progress note, which means it is part of the standard clinical record. It is not a psychotherapy note, the separate category of private process notes that receives special protection under HIPAA. Keep payer-facing content in the progress note and keep psychotherapy notes segregated.
SOAP is a strong default when your notes will be read outside your own practice: integrated primary care, hospital-affiliated clinics, multidisciplinary teams, and any setting where payer review is routine. The Objective section gives SOAP an edge over looser formats when you track measurable data such as screening scores, missed appointments, or medication changes. Solo therapists who never share records sometimes prefer DAP, which merges the subjective and objective material into one Data section.
S: Subjective. The client's report in their own frame: presenting concerns, symptoms, stressors, progress since last session. One or two short quotes can anchor the note. Pitfall: filling this section with your interpretation instead of the client's report; interpretation belongs in Assessment.
O: Objective. What you observed and measured: appearance, affect, engagement, mental status highlights, screening scores (PHQ-9, GAD-7), attendance. Pitfall: writing "client seemed anxious" as objective; describe the observable behavior instead, such as fidgeting or rapid speech.
A: Assessment. Your clinical judgment: progress toward treatment plan goals, response to interventions, diagnostic impressions, risk status. This is where the note earns its medical necessity. Pitfall: repeating S and O instead of interpreting them.
P: Plan. What happens next: interventions for coming sessions, homework, referrals, medication coordination, next appointment, any safety planning. Pitfall: a bare "continue treatment"; tie the plan to a goal.
Client: [initials] Date: Session #: Service: [individual/group/telehealth] Start/stop time: S (Subjective): O (Objective): A (Assessment): P (Plan): Clinician signature/credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: adult client, generalized anxiety disorder, CBT, session 6 of a planned 12. All details are fictional.
Client: M.T., 34 · Date: 07/08/2026 · Session: 6 · Service: Individual psychotherapy, 53 min, in office · Start/stop: 10:04 to 10:57
S: Client reported "a better week than most," rating average anxiety 4/10, down from 6/10 last session. Completed thought records on 5 of 7 days. Reported one episode of work-related rumination Tuesday lasting about an hour, managed with paced breathing. Sleep improved to 6 to 7 hours nightly. Denied suicidal ideation, self-harm urges, and substance use.
O: On time, casually dressed, good hygiene. Speech normal rate and tone. Affect euthymic, broader range than prior sessions. Engaged actively in agenda setting. GAD-7 today: 9 (down from 13 at intake). No observable psychomotor agitation.
A: Steady progress toward Goal 1 (reduce daily worry intensity and duration). Client is applying cognitive restructuring with less coaching and attributed the Tuesday episode recovery to skills practice. Symptoms remain consistent with GAD, moderating. Risk: denies ideation; no risk indicators observed; continue routine monitoring.
P: Continue weekly CBT. Introduce worry-postponement experiment next session. Homework: continue thought records, add one scheduled 15-minute worry period daily. Re-administer GAD-7 at session 8. Next appointment 07/15/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Try it freeA SOAP note is part of the designated record set: clients can request it, payers can audit it, and other providers may rely on it. Write every section as if a colleague, a reviewer, and the client will read it. Keep private reflections and hypothesis-level process material out of it; that content belongs in segregated psychotherapy notes with their own authorization rules.
For insurance work, the Assessment and Plan sections do the heavy lifting: they connect the session to the diagnosis and the treatment plan, which is the core of medical necessity. The format is a convention; the content is the requirement. For time-based psychotherapy codes (90832, 90834, 90837), Medicare contractor guidance expects start and stop times or total time in the record, documented separately from any E/M service furnished in the same visit. For telehealth sessions, add modality, client location, and consent details (see the telehealth note). For group or couples work, each client's note must stand alone without exposing the other participants' clinical content (see group and family and couples notes).
Audit findings are about documentation, not format choice. In Medicare's 2024 reporting-period data for outpatient psychiatric services, insufficient documentation drove 78.3% of improper payments, and a national OIG audit of psychotherapy claims estimated $580 million in improper payments, with missing time documentation and missing signatures among the most common problems. The BastionGPT Clinical Advisory Board sees the same errors most often in SOAP note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | Convention, not law: Medicare says progress notes "may be in any form or format"; HIPAA and payer rules govern content | Convention; record content governed by provincial privacy law and college standards (e.g. Ontario CRPO) | Convention; AHPRA expects accurate, factual, contemporaneous, attributable records |
| Terminology | Progress note, SOAP note | Clinical record, session note | Case note, session note |
| What changes | Payer and audit fields (codes, time, medical necessity) | Fewer payer-driven fields; college documentation standards lead | MBS and Better Access contexts add referral and review fields |
| Retention | No universal HIPAA rule for patient charts; state law and payer contracts govern | Provincial; Ontario CRPO expects 10+ years from last interaction, or from the client's 18th birthday | State rules; NSW requires 7 years for adults and until age 25 for minors |
The structure itself travels well across all three countries. What changes is the administrative layer around it, so adapt billing language, privacy references, and retention practices to your jurisdiction.
BastionGPT is specifically trained, tuned, and clinically tested on SOAP notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Most therapy SOAP notes run 150 to 350 words and take 10 to 20 minutes to write by hand. Long enough to show medical necessity and risk monitoring, short enough to write in the minutes after session. Length beyond that rarely adds defensibility.
No payer mandates the SOAP format itself. Medicare's Program Integrity Manual says progress notes "may be in any form or format." What payers require is content: documentation that supports medical necessity, links the session to the treatment plan, and records time for time-based codes. SOAP persists because it organizes that content well.
DAP combines SOAP's Subjective and Objective sections into a single Data section. SOAP separates the client's report from your observations, which reads better in medical and integrated care settings. See the DAP note template for a side-by-side.
No. HIPAA's psychotherapy-notes definition excludes session times, modality and frequency, diagnosis, functional status, treatment plan, symptoms, prognosis, and progress. A SOAP note kept in the chart is a progress note, part of the standard record. True psychotherapy notes must be kept apart and have their own authorization rules.
For time-based psychotherapy codes (90832, 90834, 90837), Medicare contractor guidance expects start and stop times or total time in the record, and psychotherapy time documented separately from any E/M service in the same visit. Recording start and stop times in the note header is the simplest way to stay audit-ready.
Observable and measurable material: appearance, behavior, mental status observations, engagement, and screening scores such as the PHQ-9 or GAD-7. The client's self-report belongs in Subjective; relabeling it as objective is one of the most common SOAP note mistakes.
Yes, but each client needs their own note, and no client's note should expose another participant's clinical content. The group therapy note and family and couples note pages cover the multi-client confidentiality rules.
There is no universal HIPAA retention rule for patient charts; HIPAA's six-year rule covers required documentation such as policies, not patient records. Retention comes from state, provincial, and payer rules: Ontario's CRPO expects at least 10 years from the last interaction (or from the client's 18th birthday), and New South Wales requires 7 years for adults and until age 25 for minors. Check your jurisdiction and payer contracts.
Yes. Paste a transcript, dictate, or give it bullets, and it produces a structured SOAP draft for your review. It can also convert notes you already have into SOAP format. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.