SOAP notes for mental health therapy, drafted by AI and finished by you
A practical guide to writing SOAP notes for therapy sessions, with examples, and a faster way to produce them: record or type your session summary and My Clinical Writer drafts the Subjective, Objective, Assessment and Plan for your review.
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What are SOAP notes in therapy?
SOAP is a structured documentation format used widely in healthcare and mental health to organize clinical information about a session. Each letter is a section:
S: Subjective, what the client says
The client's own words and reported experiences: presenting concerns and symptoms, progress toward goals from the client's perspective, life events and stressors discussed, and homework completion. Example: "I felt anxious about the presentation, but I used the breathing techniques we practiced."
O: Objective, what you observe
Your observations during the session: mental status findings, appearance, behavior and affect, the quality of rapport, and the client's response to interventions. Example: Client appeared calm, maintained good eye contact, affect congruent with mood.
A: Assessment, your clinical judgment
Your clinical impressions and formulation, progress toward treatment goals, changes in symptoms or functioning, diagnostic considerations and risk assessment where applicable. Example: Client demonstrating improved coping skills; anxiety symptoms decreased from severe to moderate.
P: Plan, the next steps
Interventions to continue, new techniques to introduce, homework, session frequency and any referrals or consultations. Example: Continue weekly CBT. Client to practice exposure hierarchy. Follow up in 7 days.
Example SOAP note: CBT session
Fictional sample for illustration.
Subjective: Client reports decreased anxiety this week (7/10 down to 4/10). States "I used the thought record three times when I felt anxious about the work presentation." Notes improved sleep and less rumination before bedtime.
Objective: Alert and engaged throughout session. Good eye contact. Affect more relaxed than previous sessions. Speech clear and goal-directed. Demonstrated good understanding of cognitive restructuring techniques.
Assessment: Client showing progress in managing anxiety symptoms using CBT techniques. Successfully applying cognitive restructuring in real-world situations. Homework completed. Continue current treatment approach.
Plan: Continue weekly CBT sessions. Homework: schedule two social activities this week. Review automatic thought patterns related to perfectionism. Next session in 7 days.
SOAP or DAP?
| SOAP | DAP | |
|---|---|---|
| Structure | 4 sections: Subjective, Objective, Assessment, Plan | 3 sections: Data, Assessment, Plan |
| Often used for | Medical-model settings, psychiatry, structured assessments | Talk therapy, counseling, humanistic approaches |
| Observations | A separate Objective section | Combined with the client's report in Data |
| Language | More formal clinical language | More flexible, therapy-focused language |
You can use either format, or a different one for each client. See therapy progress notes for BIRP and GIRP as well.
How My Clinical Writer drafts a SOAP note
With voice recording: record the session or a spoken summary afterwards. The AI transcribes it, separates what the client reported from your observations, and drafts each SOAP section in clinical language.
Without recording: type brief points about what the client said, what you observed, your impressions and the plan. Bullet points are fine; the AI expands them into a complete note in SOAP structure.
Then you finish it: refine the assessment, add the specific interventions you used, document progress toward goals and include a risk assessment where applicable. When it reads the way you would have written it, copy it to your EHR or save it as a Word document.
Writing tips for stronger SOAP notes
- Quote the client briefly in Subjective when the exact words matter.
- Keep Objective to what you observed, not what you inferred.
- In Assessment, link symptoms and functioning to the treatment goals.
- Make the Plan specific enough that a colleague could pick up the next session.
The AI drafts. You decide.
My Clinical Writer writes a first draft from what you record, type or upload. You review it, edit anything that does not match your clinical judgment, and only then sign or export it. The assessment, the diagnosis and the plan are always yours, and you remain responsible for the final record.
Patient data is protected as described on our security and HIPAA page: 256-bit encryption in transit and at rest, role-based access, audit trails, and a Business Associate Agreement that every account accepts at registration.
Questions, answered.
Are SOAP notes required for therapy documentation?
No single format is legally required, but payers and organizations expect notes that capture the clinical information and medical necessity behind each session. SOAP and DAP are two of the most common ways to do that. Check what your payers and organization ask for.
Can I use SOAP notes for every type of therapy?
Yes. The format works for CBT, DBT, psychodynamic therapy, EMDR, couples and family therapy and more. It is flexible about content while keeping a predictable structure.
What is the difference between SOAP and DAP notes?
SOAP has four sections (Subjective, Objective, Assessment, Plan), DAP has three (Data, Assessment, Plan). SOAP keeps the client report separate from your observations; DAP combines them. My Clinical Writer supports both, and you can switch per client.
Will the AI add things that did not happen?
The AI drafts from your recording, notes and documents, but any AI can misread or overstate something. That is why you review every note before it is final: check each section against what actually happened in the session, and edit freely.
Can I customize the SOAP template?
Yes. Create SOAP templates for different client groups, presenting problems or modalities, with your own section instructions, preferred phrasing and the elements you always include, such as session duration or a risk statement.
Is client information secure?
My Clinical Writer is HIPAA and PHIPA compliant, with 256-bit encryption in transit and at rest, access controls and audit trails. Every account accepts our Business Associate Agreement at registration. See the security page.
Try it on your next note.
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