On a recent poll in one of my counseling social media groups, the moderator asked what each member wished they could have learned more about in graduate school. Members overwhelmingly answered that they felt they were under prepared to write progress notes once they started seeing clients in the “real world”.
Progress notes are essential to any practice and serve several purposes during the therapy process:
- Record of events during treatment process
- Allows you to track client’s progress
- Provides standardized form of communication between professionals
- Protects you as the clinician in a multitude of cases such as an audit
For this reason, I decided to write up a quick guide to writing case notes, specifically SOAP (subjective, objective, assessment, plan) notes. I have found that even with a standardized model for progress notes, there is still a lot of variety in the style and template depending on setting and/or supervisor preference. For example, in a free clinic, I was expected to use SOAP notes. In a college counseling setting, my supervisor preferred a more narrative style. In my current setting with a behavioral health agency, I use the PAIP model (problem, assessment, interventions, and plan). I would suggest you review the documentation preferences and requirements of your particular agency or setting.
See below for a more detailed explanation of each part of the SOAP note and check out the SOAP note template found at the end of this page.
To me, this is the meat of the SOAP note sandwich (or portobello mushrooms for my vegetarian/vegan friends). It includes the client’s chief complaint or presenting problem. This is the section where you would put direct client quotes of clinical significance since the client provides the information for this section. Do not include any names the client references in the note (i.e. “client’s wife” instead of “Mary”). You can also use action verbs to describe what you did in session. See below for common action verbs for clinicians:
S : Client reported he had decided on moving into public housing since last speaking with counselor. Praised client for prioritizing his goal of finding safe housing. Client stated he still had concerns that were “taking a toll”. Reviewed client’s concerns which included affordability of new housing and the possibility of moving into a new neighborhood. Validated client’s concerns. Assessed client’s readiness to move into new housing on a scale from 1-10 with 10 representing maximum readiness. Client rated himself at a 9. Reviewed client’s long-term goal of finding permanent housing. Discussed possibility of client making a list of experiences he was looking forward to upon moving into his new apartment. Client verbally agreed to homework.
For those of you who have completed a mental status exam, this is where you can put objective information you notice about a client such as appearance, speech, mood and affect, orientation (to time and place, etc), concentration and memory, and insight. This is the section of the SOAP note where you might see the most variance depending on setting and what your employer expects. In an agency setting, I usually take note of mood and affect and any noticeable or unusual behaviors. You can find more details about the Mental Status Exam here.
O : Client dressed casually for session in jeans and t-shirt. Client’s mood anxious, affect normal and appropriate to context. Speech pressured. Client began tapping foot when discussing moving into new housing.
O : Client’s mood anxious, affect normal. Client exhibited normal content behavior.
This is personally my favorite part of the note because I love assessment, diagnosis and problem solving (solution-focused much?). The assessment part of your SOAP note can really range in detail depending on setting, the model you use, and your supervisor’s preferences. In a medical model, your assessment might include a diagnosis and a differential diagnosis (an additional but less likely diagnosis or diagnoses that could also explain symptoms) that you have concluded from your gathered subjective and objective information. In a wellness model, the assessment might include more information about the counselor’s impressions and client progress. This answers the question “Why is the client experiencing these symptoms or exhibiting these behaviors?”.
A : Client has gained insight on need for safe housing. Client expresses continuing anxiety related to increased financial insecurity and possibility of moving into new neighborhood. Client has difficulty focusing on potentially positive future experiences.
In the plan section of the SOAP note, you write a quick blurb on the plan for the next session possibly including place and time of next meeting, focus of next session, any assignments or special interventions. Your plan, like the rest of the note, should reflect your theory and the client’s treatment plan.
P: Review homework and discuss how client has coped during previous adjustments to housing. Refer client to agency housing specialist for any additional questions specific to public housing.
SOAP Note Template