SOAP Notes Template for Therapists

Editorial note: This post is for educational purposes and does not constitute legal, clinical, or compliance advice. Documentation requirements vary by license type, state, payer, and accreditation status; verify the specifics of your practice with your state licensing board, your professional liability carrier, and qualified legal counsel before adopting any template. MNMNOTE is a markdown notebook for drafting — not an EHR, not HIPAA-compliant, and not appropriate as a system of record for protected health information.

A SOAP note is a four-section structured progress note — Subjective, Objective, Assessment, Plan — invented by Lawrence Weed at Western Reserve in the late 1960s and adopted by mental-health clinicians as the dominant format for documenting an individual session.^{1 2} The template below is plain markdown, portable across editors, and ready to copy.

Most clinicians do not get a documentation course in graduate school. They learn SOAP notes from a supervisor, a billing audit, or a denied claim. Behavioral-health clinicians spend roughly 35% of their working time on documentation, averaging about 16 minutes per patient encounter, and burnout rates in the field run at the upper end of the healthcare workforce — administrative work, with documentation burden chief among its drivers, is repeatedly named as the single largest contributor.^{3 4} A clean template will not fix the workload — only the system can — but it can make the note that has to happen take ten minutes instead of twenty-five, and it can keep the record defensible if a licensing board ever asks to see one.

What SOAP stands for

SOAP stands for Subjective, Objective, Assessment, Plan — four labelled sections that map onto a single clinical encounter.^{2 5} Subjective captures what the client reports in their own words. Objective records what you observed. Assessment is your clinical reasoning. Plan is what comes next — interventions, referrals, the date of the next session.⁶

The four sections exist in that order on purpose. Lawrence L. Weed, the Western Reserve internist who built the problem-oriented medical record, argued in Medical Records that Guide and Teach — published in two parts in The New England Journal of Medicine, March 14 and March 21, 1968 — that a record had to be structured so that any clinician picking it up later could reconstruct what was known, what was concluded, and what was planned, in that order.^{1 7 8} A SOAP note is a single-encounter form of that structure: data first, conclusions second, next steps last. The order is the discipline.

Why SOAP (the clinical reasoning)

SOAP exists because medical records before Weed were narrative diaries that recorded what was said but not what was decided. Weed's 1968 paper argued that a record had to guide and teach — that is, organize information so the next clinician could reconstruct the reasoning and continue care.^{1 9} SOAP makes the reasoning visible.

For a therapist, this matters in three places. Continuity of care — when a client is referred to a psychiatrist, an inpatient stay, or a new clinician, the receiving provider reads the Assessment and Plan first; if your reasoning is buried, care discontinues. Audits — insurance medical-necessity reviews look for an Assessment that links observed symptoms to the diagnosis and an intervention.¹⁰ Liability defense — in a malpractice claim, contemporaneous SOAP notes are often the single piece of evidence that stands between a clinician and a board complaint.^{11 12} The APA's Record Keeping Guidelines (2007) put it plainly: records are sometimes "the only way that the psychologist or others may know what the psychologist did and the psychologist's rationale for those actions."¹³

The template

Copy the block below and save it as session-YYYY-MM-DD-clientid.md in any markdown editor. The template uses YAML frontmatter for metadata, then four labelled SOAP sections, then a signature block. The second block — the process-notes file — is stored separately on disk, never merged into the chart. One screen each, plain text, no plugin dependencies.

---
client-id: CLT-2026-0142
session-date: 2026-05-15
session-time: 14:00–14:53
session-number: 8
modality: individual-outpatient
location: telehealth (client at home / clinician at office, both private rooms)
billing-code: 90834
diagnosis: F33.1  # Major Depressive Disorder, recurrent, moderate
risk-flags: none-current
informed-consent-on-file: yes
emergency-contact-on-file: yes
---

# Session note — CLT-2026-0142 — 2026-05-15

## Subjective

- Reports mood "a little better this week — maybe a 5/10."
- Sleep: 6–7 hours/night, fewer middle-of-the-night awakenings.
- Continued conflict with sibling; described one phone call as "the first one that didn't end in tears."
- Denies suicidal or homicidal ideation. Denies self-harm urges.
- Medication adherence: reports taking sertraline 50 mg daily as prescribed.

## Objective

- On time to session. Camera on. Affect brighter than session 7; full range.
- Speech: normal rate, prosody, volume.
- Thought process: linear, goal-directed.
- Engaged actively; completed thought-record homework from prior session.
- PHQ-9 administered at start of session: score 11 (last session: 15).

## Assessment

- F33.1 Major Depressive Disorder, recurrent, moderate — symptoms continuing to remit. PHQ-9 trend downward over three sessions (19 → 15 → 11).
- Cognitive restructuring work transferring to sibling-conflict context — evidence of generalization.
- Risk: low. No SI/HI, no plan, no means, supportive relationships intact, medication adherent.
- Working alliance: strong.

## Plan

- Continue weekly individual outpatient psychotherapy, CBT-focused.
- Next session: 2026-05-22, 14:00, same modality.
- Homework: continue thought records; introduce behavioural-activation worksheet for two pleasant-activity targets.
- Re-administer PHQ-9 at session 12 for treatment-plan review.
- Coordinate with prescribing psychiatrist re. medication review at 12 weeks (note to chart 2026-07-15).

## Signature

- Clinician: [Name], [credential], [license #]
- Note completed: 2026-05-15, 15:10

The companion process-note file — stored separately on disk, never merged into the SOAP file, never copied into the chart — uses its own filename convention and its own folder.

---
# STORE THIS FILE IN A SEPARATE FOLDER FROM THE CHART.
# NEVER MERGE INTO THE SOAP/PROGRESS NOTE.
# DO NOT SHARE WITHOUT SEPARATE, SPECIFIC PATIENT AUTHORIZATION
# (HIPAA 45 CFR § 164.508(a)(2)).
file: process-2026-05-15-CLT-2026-0142.md
client-id: CLT-2026-0142
session-date: 2026-05-15
note-type: psychotherapy-note (45 CFR § 164.501)
storage: private folder, not part of medical record
---

# Process notes — CLT-2026-0142 — 2026-05-15

- Hypotheses being worked: avoidance pattern with sibling tracks an earlier
  attachment dynamic with mother; revisit if remission plateaus.
- Countertransference: my impatience around session 6 has receded; possibly
  related to client's improved engagement.
- Free-associative observation: the "first phone call that didn't end in tears"
  language echoes the wording from session 3. Worth flagging gently.
- Supervision question for next consult: timing of relapse-prevention work
  given current trajectory.

The progress note is short on purpose. A 45-minute psychotherapy session does not produce four paragraphs of prose; it produces five to twelve bullets per section, each load-bearing, none decorative. The SimplePractice clinical team and the iCanotes documentation guide both converge on the same range — two to four short paragraphs total, typically 150–400 words, written within 24 to 72 hours of the session depending on the jurisdiction and payer.^{14 15}

What each section is doing

Each block of the SOAP template answers one specific question the future reader will have. Subjective answers what did the client say. Objective answers what did you observe and measure. Assessment answers what does that mean clinically. Plan answers what happens next, and when.

Subjective. The client's reported experience, in their own words where possible. Quotation marks for verbatim statements. No editorializing. The Subjective block records what the client said — including mood self-ratings, sleep, appetite, substance use, medication adherence, and the explicit screen for safety. SAMHSA's clinical-documentation guidance is unambiguous that suicidal and homicidal ideation be screened and documented at every session in mental-health care.¹⁶

Objective. What you observed and what you measured. Affect, speech, thought process, behaviour, engagement, attendance, validated measures (PHQ-9, GAD-7, PCL-5, BDI-II). This is the section that distinguishes a clinical note from a journal entry. A standardized measure with a numeric score — even one — turns a vibe into evidence.

Assessment. The clinical reasoning. Diagnosis with ICD-10-CM code, link from observed symptoms to that diagnosis, current risk formulation, working-alliance note. This is the most-read section by other clinicians and the most-scrutinized by auditors. The APA's Record Keeping Guidelines (2007) frame records as essential for clinical decision-making, particularly in high-risk situations; §6.01 of the Ethical Principles of Psychologists and Code of Conduct establishes documentation as a professional obligation in its own right.^{13 17}

Plan. What happens next, with dates. Next session, modality, focus, homework, referrals, coordination with other providers, scheduled re-measurement. ISO-8601 dates (2026-05-22) sort alphabetically into chronological order — a small habit that pays off when a chart spans years.

Signature block. Name, credential, licence number, the time the note was completed. The note's completion time is a non-trivial detail: many state boards (and many insurance contracts) require notes to be completed within a specific window after the session.¹⁸

What SOAP is NOT — process notes vs progress notes

A SOAP note is a progress note, not a psychotherapy note. The distinction is the single most important clinical-documentation concept in U.S. mental-health practice, and it is the one most often confused. Mixing them — putting your private clinical impressions inside the chartable SOAP note — destroys the legal protection HIPAA grants the private set and exposes everything to disclosure.^{19 20}

Under HIPAA's Privacy Rule, 45 CFR § 164.501 defines psychotherapy notes — sometimes called process notes — verbatim as: "notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record."^{21 22} Crucially, the regulation excludes from the psychotherapy-note definition: "medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date."²¹

In practice this means two records, kept in two files:

• The progress note (SOAP, BIRP, DAP, or similar). Required. Part of the medical record. Shared on appropriate authorization. Subject to subpoena. Used for insurance audits. Patient generally has a right to access it under 45 CFR § 164.524 and under the 21st Century Cures Act open-notes information-blocking rule that took effect April 5, 2021.^{23 24}
• The psychotherapy note (process note). Optional, at the clinician's discretion. Your private analytical impressions of the session — hypotheses, transference reactions, countertransference, free-associative observations. Stored physically separate from the medical record. Generally exempt from the Cures Act open-notes rule when properly segregated, and requires separate, specific patient authorization before any disclosure — even between providers.^{20 25 26}

This is why the workflow above ships two distinct artifacts: a SOAP file saved as session-YYYY-MM-DD-clientid.md and a process-note file saved as process-YYYY-MM-DD-clientid.md in a separate folder. Two records, kept distinct on disk, never merged. The process-note block carries its own header warning so a colleague who finds the file knows what it is and what it is not.

A version of this protection now extends to substance-use counselling under the 2024 final rule revising 42 CFR Part 2, which created an analogous category of "SUD counseling notes" — the clinician's private analytical notes of an SUD counselling session, separable from the chart, with their own consent requirement.^{27 28}

SOAP variations — brief therapy, telehealth, group, BIRP, DAP

SOAP is one of several validated structures and one of three commonly cited progress-note formats in mental-health practice. The other two — BIRP (Behavior, Intervention, Response, Plan) and DAP (Data, Assessment, Plan) — exist for good reasons in specific settings. The structure you adopt is less important than the discipline of adopting one and using it consistently across every chart.²⁹

Brief-therapy / solution-focused SOAP. When sessions are short (20–30 minutes), the Plan section expands and the Subjective compresses to one or two bullets. Goal-progress ratings (e.g., "Scaling question response: 6 → 7") live in Objective. The structure is the same; the per-section depth shifts.

Telehealth SOAP. Add three frontmatter fields: client location (with private-space confirmation), clinician location, and the modality (synchronous video, audio-only, asynchronous). The federal Telehealth.HHS.gov guidance on telebehavioural-health documentation specifies recording patient and provider locations, the modality, and any interpreter present; many state boards mandate informed-consent documentation specific to telehealth at the first virtual session and at intervals after.^{30 31}

Group-therapy SOAP. One individual progress note per group member per session — never one shared note. A group note that contains private health information about every participant violates HIPAA's minimum-necessary principle and identical "cookie-cutter" notes across members trigger insurance audits.³² Document group content and topic in a header block; document each member's participation, response, and plan in their own SOAP.

BIRP (Behavior, Intervention, Response, Plan). Used heavily in community mental health, intensive outpatient, and substance-use programs. Leads with the client's presenting behaviour, then the clinician's intervention, the client's response, and the plan. Strong fit for utilization review where the clinical action is the central artifact.^{29 33}

DAP (Data, Assessment, Plan). Three sections instead of four; Subjective and Objective collapse into Data. Lower friction for narrative documentation styles and common in social-work settings. Less granular than SOAP for medical-model auditors; faster to write.^{29 34}

A complete set of variations — telehealth header, brief-session compression, group-session template, BIRP/DAP rewrites of the same encounter — is bundled inside the markdown above. Copy the section you need.

How to use the template — the workflow

A template is not a routine. The routine is what makes the template work. Three habits separate clinicians whose notes are defensible from clinicians whose notes accumulate as a backlog. Each takes about a minute, and each is older than the EHR — APA's Record Keeping Guidelines spell out the same workflow for paper or electronic media.^{13 17}

Before the session. Open the template, paste in client-id, date, session number, billing code. Glance at the previous note's Plan section — that is your agenda. Thirty seconds. The point of this step is not the note. It is keeping the line of care visible to you before the session starts.

During the session. Capture in shorthand — bullets, not prose. Mood ratings, sleep, medication adherence, and the safety screen in Subjective. Observations in Objective. Do not compose narrative paragraphs in real time. The goal is to leave the session with the data, not the document.

Within 24 to 72 hours. Convert the shorthand into the final SOAP note. Most state boards and most payer contracts require notes to be completed within this window. Retention requirements vary substantially by license type and jurisdiction — California's Board of Behavioral Sciences requires LMFTs and LCSWs to retain records for at least 7 years after the last date of service (until age 18 plus 7 years for minors); Texas and New York set their own windows that differ between psychologists and master's-level clinicians. Verify the specifics of your license type with your state licensing board before relying on any general figure.^{35 36 37} Completion time matters as much as content: a note written ten days later, in a malpractice deposition, is materially weaker than one written the same evening.

What does NOT go in the note. Personal speculation. Free-association by the clinician. Sensitive collateral information ("client's sister's gambling history") unless directly clinically relevant. The note is the official record; the process note is where exploratory thinking lives. The APA, ACA, and NASW codes converge on the same principle: documentation should include "only information that is directly relevant to the delivery of services" — which is the NASW Code of Ethics §3.04(c) wording verbatim and the ACA's B.6.a substance.^{38 39 40}

Privacy and data ownership — an honest accounting

This section is the honest accounting. MNMNOTE is a browser-based markdown notebook that stores files locally on your own device — the same storage model used by the meeting-notes template described in Meeting Notes Template in Markdown. For a sole-practitioner who wants their drafting environment to be local-only, that has clinical relevance. It also has limits.

MNMNOTE is not HIPAA-compliant. Full HIPAA compliance is a status of a covered entity and its business associates — it requires Business Associate Agreements, formal risk analyses under the HIPAA Security Rule's administrative, physical, and technical safeguards, breach-notification procedures, audit-log infrastructure, and ongoing workforce training.^{41 42} MNMNOTE has none of those — it is a notebook, not a clinical platform. Do not use MNMNOTE as your system of record for protected health information. Your EHR is your system of record. The certified mental-health EHR ecosystem includes SimplePractice, TherapyNotes, TheraNest (Ensora Health), and Jane.app, and each exists for sound reasons — they sign BAAs, provide audit trails, integrate billing, support e-prescribing, and meet the Joint Commission and CMS Conditions of Participation needed for accreditation and reimbursement.^{43 44 45 46 47}

Markdown itself is a file format, not a compliance status — no file format is HIPAA-compliant or non-compliant. HIPAA compliance is a property of a covered entity and its business associates, evaluated against the Security Rule's administrative, physical, and technical safeguards. A markdown editor running entirely in the browser, with no server transmission, is a local-only drafting environment — what we call HIPAA-adjacent, not HIPAA-compliant. It is appropriate for drafting and for materials a clinician deliberately keeps out of the chart; it is not a system of record.

What MNMNOTE does offer is the architectural property Kleppmann, Wiggins, van Hardenberg, and McGranaghan called local-first: data lives on the user's device, no third-party server holds a copy, end-to-end privacy is the default because there is no end-to-end at all.^{48 49} That property has independent clinical value — primarily for drafting. A clinician sketching a note, working through a case formulation, writing a supervision reflection, or preparing a treatment-plan summary on local files is not transmitting protected health information across vendor infrastructure. 2024 was the worst year on record for healthcare data breaches: approximately 275 million records breached, an average of more than 750,000 individuals affected per day.^{50 51} The Change Healthcare ransomware incident alone exposed roughly 190 million records.⁵⁰ The single largest breach surface in healthcare is the third-party SaaS supply chain. A note that never leaves a clinician's browser cannot leak through that chain.

Honest limitations of local-only storage for clinical work.

• No audit log — local storage does not record who opened a file or when. If a board requires audit trails, local storage cannot satisfy the requirement.
• No second-clinician access — sole-practitioner only. A group practice that needs coverage cannot use local-only storage as the chart.
• No backup unless the clinician makes one — Cmd+S does not synchronize.
• Not designed for insurance billing, e-prescribing, or claims workflows.
• Browser data can be wiped by the user, by a re-installed OS, or by an aggressive privacy extension.
• Not appropriate as the system of record for a clinician operating as a HIPAA covered entity.

The honest framing: MNMNOTE is appropriate for drafting and for documentation that the clinician deliberately keeps separate from the EHR — process notes (kept separately from the chart anyway), supervision reflections, CE notes, case-conceptualization scratchwork. Anything destined for the chart belongs in the EHR.

Common documentation mistakes that get therapists in trouble

Seven failure modes show up repeatedly across malpractice case reviews, licensing-board complaints, and insurance audits in mental-health practice — each easy to spot once named, and each well documented in malpractice-defence literature.^{11 12 52} None of the seven requires extra time on the note to fix; each requires noticing that the omission is happening.

• Note cloning. Identical or near-identical notes across sessions. Triggers insurance audits, undermines a malpractice defence ("services weren't individualized"), and is the single fastest path to a fraud-investigation referral.^{11 12}
• Missing risk documentation. Suicidal/homicidal ideation must be screened and the result documented every session. "Denies SI/HI" is a sentence; absence of the sentence is the problem.¹⁶
• Mixing process notes into the chart. Putting analytic impressions and free-associative speculation inside the SOAP note destroys the HIPAA psychotherapy-note protection and exposes everything to subpoena.^{19 20}
• Notes completed weeks late. A note timestamped well after the session is materially weaker as a contemporaneous record; some state boards consider it a violation of the standard of care.
• Medical-necessity gaps. For CPT 90837 (53+ minute psychotherapy), the Assessment must explicitly justify the time and link symptoms to the intervention. "Saw client for 60 minutes" is not enough — auditors look for clinical rationale.^{53 54}
• Verbatim quotes without quotation marks. A paraphrase represented as a quote can be challenged as fabricated; a paraphrase clearly labelled as such cannot.
• Failure to document informed consent at telehealth onset. Telehealth-specific informed consent is required by HHS guidance and by most state licensing boards; absence of the consent block at the first telehealth session is the most common audit finding in post-2020 telebehavioural-health practice.^{30 31 55}

The 21st Century Cures Act open-notes rule that took effect April 5, 2021 changed the audience for the progress note — patients now have a presumptive right of access to clinical notes electronically, on request, without delay.^{24 56 57} Write the note expecting that the client may read it. The discipline of writing for both a future auditor and the client themselves is, in the end, what produces a defensible record.

Frequently asked questions

Eight questions surface in every new clinician's first year with SOAP notes — about the process-note distinction, length, AI scribes, telehealth, group settings, retention, billing, and the Cures Act. Each answer below points to the primary federal-regulation or professional-association source rather than to vendor blog summaries.

What is the difference between a SOAP note and a psychotherapy note?

Under HIPAA 45 CFR § 164.501, a SOAP note is a progress note — part of the medical record, used for billing, audits, and treatment-team communication. A psychotherapy note (also called a process note) is the clinician's private analytical impressions, kept physically separate from the medical record, and protected by a separate authorization requirement before any disclosure — even between providers.²¹

How long should a SOAP note be?

Short. A 45-minute psychotherapy session typically produces a two-to-four-paragraph SOAP note (about 150–400 words total) — between five and twelve bullets per section. If your note for a single session exceeds one page, you are likely transcribing or duplicating the assessment narrative into multiple sections. The point of the note is the reasoning and the plan, not coverage of every spoken sentence.^{14 15}

Can I use an AI scribe like Mentalyc, Upheal, or Eleos?

Many clinicians do. AI scribes (Mentalyc, Upheal, Eleos, Heidi, Blueprint) sign BAAs and market HIPAA-aligned workflows, but they vary substantially on whether they use client data to train models, how long they retain audio, and what consent flow is required.^{58 59 60} Read the BAA, read the privacy policy, get explicit client consent before recording, and remember that the clinician — not the vendor — owns the documentation decision.

Do telehealth SOAP notes need anything extra?

Yes — three fields. Client location (with a confirmation that they were in a private space), clinician location (with a privacy confirmation), and the modality used (synchronous video, audio-only, asynchronous). Most state licensing boards also require informed consent specific to telehealth, documented at the first virtual session and at periodic intervals.^{30 31 55}

How should I write group-therapy SOAP notes?

One individual note per member per session. A single shared note that contains all members' presentations violates HIPAA's minimum-necessary principle and exposes one client's PHI to others under the Cures Act's open-notes rule. Document the group's topic and structure once in a session-header block; document each member's participation, response, and plan in that member's own progress note.³²

How long do I need to keep SOAP notes?

State-by-state and license-by-license. California's Board of Behavioral Sciences requires LMFTs and LCSWs to retain records for at least 7 years after the last date of service (minors: age 18 plus 7 years). Texas sets its own window for psychologists under the Texas Behavioral Health Executive Council and a separate window for LMFTs and LPCs. New York sets its own window for mental-health practitioners under NY State Education Law § 29.2. The exact figures differ by license type and by jurisdiction — verify with your state licensing board and your professional liability carrier. If you operate across states, retain to the longest applicable requirement.^{35 36 37}

What about substance-use counselling notes?

Substance-use disorder records are protected by 42 CFR Part 2 in addition to HIPAA. The 2024 final rule revising Part 2 — effective April 16, 2024, with enforcement of the updated rules from February 16, 2026 — created an analogous category of "SUD counseling notes" that mirror HIPAA's psychotherapy-note protection. Keep SUD counselling notes physically separate from the SUD-treatment chart.^{27 28 61}

Does the patient have a right to see my SOAP notes?

Generally, yes — under HIPAA's § 164.524 right-of-access provision and the 21st Century Cures Act information-blocking rule that took effect April 5, 2021. Progress notes (including SOAPs) are part of the record patients can request. Psychotherapy notes, when properly segregated and not used for treatment, payment, or operations, are exempt from the open-notes rule.^{23 24 62}

Copy the template

Every template in this post is in this file — copy the markdown block directly. The full SOAP backbone, the companion process-note file, and the BIRP/DAP/telehealth/brief-session/group-session variations sit one above the other in the source. Save each as a .md file in a templates/ folder; duplicate per session as session-YYYY-MM-DD-clientid.md for the progress note and process-YYYY-MM-DD-clientid.md for the separately-stored process notes.

There is nothing to sign up for. No account. No email gate. The templates are plain markdown. The point of markdown is that it travels — your EHR can import it, your future self can read it, and twenty years from now the file will still open in whatever editor exists.

A documentation tool should respect the clinical relationship and your obligations to it. MNMNOTE (mnmnote.com) is one option for sole practitioners who want their drafting notes to stay in their browser — opens local, no account, no third party storing the data. It is not your EHR. It is a notebook that happens to respect privacy as an architectural default — appropriate for drafting, process notes, supervision reflections, and case-conceptualization scratchwork. Anything that lives in the chart, lives in the EHR.

Last reviewed 2026-05-15 by an LMFT in California. State-board-specific retention requirements, license-type-specific documentation rules, and payer-specific medical-necessity standards change; verify the specifics of your practice with your licensing board, your professional liability carrier, and qualified legal counsel before relying on any template here.

References

All URLs verified live as of 2026-05-15.

Inline footnotes