SOAP Notes

Objective for the session: In one sentence, what did you plan to do?

S: (Subjective) What are the most striking things that your client said? Often using your client's own words is desirable.

O: (Objective) What do you see? Use observations rather than inferences.

A: (Assessment) What did you conclude from your observations? Your assessment should follow from your S & O.

P: (Plan) When do you plan to meet next? What will you do next time? What homework, if any, did you give? This should match the session objective for your next session and should follow from A. Sign and date your note, adding your title.

Remember, notes should:

• Be succinct, only focusing on the most important aspects of the session.

• Be objective. Others watching your session should be able to agree with what you saw.

• Be strength-based. Write as you would like to be written about. (Clients have the right to read what you write about them.) This does not mean that you need to lie, play pollyanna, or obscure. Just be respectful.

• CYA. Document your client's suicidality, homicidality, and anything you did to keep your client and significant others safe.

• CYCA. Every piece of information does not need to be in your note, especially information that might embarrass your client if he or she were to read it or it were to end up in court.

  Grading the SOAP

  An example

  Page by jms
  URL= http://psy1.clarion.edu/jms/intsoap.html

  Last updated January 8, 2004