A useful SOAP note example shows the judgement behind each line, not just the layout. The four worked examples below cover a first appointment, a telehealth session, a session where risk was raised, and a missed appointment. Each one is annotated against the record standards Australian practitioners are actually held to.
Most SOAP examples online show a tidy note and stop there. The harder question is why one Objective line will hold up in a subpoena, an audit or a handover and another will not. Every example here is fictional, and every annotation points back to a published requirement rather than a preference. For the format itself, see our complete guide to SOAP notes and the SOAP note template and formatting guide.
What standard should a SOAP note example meet?
Section 8.3 of Ahpra's shared Code of conduct sets out what good practice looks like. It says good practice includes that you:
- "keep accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings ... in a form that can be understood by other health practitioners"
- "ensure that records show respect for patients and do not include demeaning or derogatory remarks"
- "make records at the time of events or as soon as possible afterwards"
- "recognise the right of patients to access information contained in their health records and facilitate that access"
Ahpra's Managing health records page condenses the same expectations into five points, two of which also sit in law: Australian Privacy Principle 11 requires reasonable steps to protect personal information "from misuse, interference and loss, and from unauthorised access, modification or disclosure", and APP 12 governs client access requests, per the OAIC's quick reference.
A practical test falls out of that. Write every note as though the client will read it, another clinician will rely on it, and a reviewer will ask when you wrote it.
What separates a weak SOAP line from a strong one?
The format is rarely the problem. The content of each line usually is. Weak: "Client reported a bad week. Presented as anxious. Doing okay, some progress. Continue as discussed." Strong: "Reports four nights of broken sleep, waking around 3am, and cancelled two shifts. DASS-21 anxiety subscale 18, up from 14 on 12 June. Sleep disruption and work avoidance match the pattern recorded at intake, so this reads as a short-term deterioration rather than a change in formulation. Client to complete a sleep diary for two weeks; clinician to repeat the DASS-21 on 24 July."
Three habits do most of the work: report what was said and seen rather than your impression of it, keep your reasoning in the Assessment section, and give every Plan action an owner and a date.
SOAP note example: a first appointment
Session 1, 50 minutes, in rooms. Client "J", 34.
Subjective. Self-referred after a GP mental health treatment plan. Reports six months of low mood, loss of interest in social contact, and difficulty concentrating at work, worsening since a role change in March. Reports two to three standard drinks most evenings, up from weekends only. Says his goal is "to stop dreading Monday". Denies current thoughts of self-harm.
Objective. Presented on time, oriented and cooperative. Affect flat, speech slowed, engaged well after the first fifteen minutes. K10 administered: score 29. Consent to treatment and privacy information discussed, and written consent recorded on file.
Assessment. Presentation is consistent with a moderate depressive episode with a clear temporal link to the March role change, and the K10 score corroborates the reported severity. Increased evening alcohol use is a maintaining factor to monitor rather than a separate treatment focus at this stage. Risk assessed as low today on the basis of the denial of current ideation, intact supports and no history of self-harm.
Plan. Behavioural activation as the initial approach, six sessions, reviewed at session four. Client to record daily activity and mood ratings before the next session. Clinician to write to the referring GP within one week with the client's consent. Next appointment 6 August. Re-administer K10 at session four.
Why it holds up: the risk statement records the basis for the conclusion rather than the conclusion alone, the score is dated so a later comparison is meaningful, and every Plan item names who does it and by when.
SOAP note example: a telehealth session
Ahpra's telehealth guidance asks practitioners to confirm the patient's identity, to check their environment "adequately protects privacy and confidentiality", to obtain informed consent including "for the use of any AI scribes", and to "maintain clear and accurate records of the consultation". A telehealth note should show those checks happened.
Session 5, 45 minutes, video.
Subjective. Client confirmed identity and date of birth at the start of the call and confirmed she was alone at home with the door closed. Reports the sleep diary was completed for eleven of fourteen nights, and two panic episodes in the fortnight, both at work, shorter than previous episodes and managed with paced breathing.
Objective. Video adequate apart from a 90 second dropout at approximately 20 minutes, after which the session resumed with the client's agreement. Consent to the use of an AI scribe confirmed verbally at the start and recorded here. Sleep diary reviewed on screen: average sleep 5.5 hours, two nights above 7. Panic frequency down from five episodes a fortnight at session 1.
Assessment. Panic episodes are reducing in frequency and duration, and the client is applying paced breathing during the episode rather than after it, which is the change targeted in sessions 2 to 4. Sleep remains below the agreed target and is the main barrier to further gains. Telehealth remains clinically appropriate: the client engaged as fully as in rooms and the dropout did not affect the assessment.
Plan. Continue interoceptive exposure homework, three sessions per week. Client to trial a fixed wake time for two weeks. Clinician to send the sleep hygiene handout by secure message today. Next session by video on 20 August.
Why it holds up: identity, environment and consent are recorded as facts rather than assumed, the dropout is documented alongside its clinical effect, and the note revisits whether telehealth is still appropriate.
SOAP note example: a session where risk was raised
This is the note most likely to be read by someone other than you. Write it during or immediately after the session.
Session 3, 60 minutes, in rooms.
Subjective. Client disclosed passive thoughts of "not wanting to wake up", present most days for the past two weeks, worse in the evenings. Denies intent, plan or preparatory acts. Reports the thoughts follow arguments at home and reduce after contact with his sister. Agreed his sister could be named as a support contact.
Objective. Tearful for approximately ten minutes when discussing home conflict, settled without prompting. Oriented, no perceptual disturbance reported or observed. Structured risk review completed in session. K10 administered: 34, up from 29 at intake.
Assessment. Risk of self-harm assessed as low to moderate and elevated on the previous session, driven by passive ideation, the K10 rise and the home conflict. Protective factors are active: engagement in treatment, a willing family support and no intent or plan. The presentation does not meet the threshold for acute referral today, and it does warrant a shortened review interval.
Plan. Safety plan completed collaboratively in session, copy given to the client and copy on file, including his sister's number and the Lifeline number. Clinician to phone the GP today with the client's verbal consent, recorded here, and to send a written summary within 48 hours. Next appointment brought forward to 20 August. Review risk at every session until the K10 falls below 30.
Why it holds up: the disclosure is quoted rather than paraphrased into a diagnosis, the risk conclusion names the factors on both sides, consent for the GP contact is recorded, and the review interval changes in a way a reader can see. Our guide to mental health progress notes covers the wider documentation trail around risk.
SOAP note example: a missed or cancelled appointment
Missed appointments are part of the clinical record. A short note is enough, and no note at all is the problem.
Subjective. Client did not attend a scheduled 10am appointment. No contact received before the appointment time.
Objective. Reminder message sent 24 hours prior and delivered. Practice called at 10:15am, no answer, voicemail left inviting the client to rebook. Second non-attendance in six weeks.
Assessment. Pattern of non-attendance since the change in shift roster reported at session 4, rather than indicated disengagement from treatment. No risk indicators recorded at the last session on 30 July.
Plan. Follow-up SMS today with rebooking options. If no contact by 16 August, clinician to write to the referring GP as agreed at intake. Fee not applied on this occasion.
Why it holds up: it records what the practice did, not only what the client did not do, and links the pattern to something already in the file.
What do the four examples have in common?
- They were written at the time of the session or immediately after it.
- They keep interpretation out of the Subjective and Objective sections.
- Every score is dated and comparable to an earlier one.
- Every Plan item has an owner and a date.
- Nothing in them would embarrass you if the client requested access, which they are entitled to do under APP 12.
- They are specific enough that another clinician could pick up the file cold.
Software handles the mechanics: templates keep the sections consistent, an AI scribe drafts the Subjective and Objective content so the note is finished before you leave the room, and assessment scores carry forward so comparisons are accurate. PractaLuma is AI-native practice management software for Australian mental-health practices, and its clinical notes, AI scribe and standardised assessments features are built around this workflow, with plans on the pricing section. The clinical judgement in the Assessment section stays yours.
Where are the SOAP examples for your discipline?
- Counselling and psychology presentations: SOAP note templates for mental health counselling
- Occupational therapy: OT SOAP notes, examples and template
- Speech pathology: paediatric SOAP notes for speech therapy
- Choosing between formats: SOAP, BIRP and DAP compared, and the DAP note examples guide
Frequently asked questions
How long should a SOAP note be?
Long enough to satisfy continuity of care and no longer. The examples above run from about 100 words for a non-attendance to a little over 200 for a first appointment or a risk review, because there is more in those that a later reader needs.
Can I copy a SOAP note example straight into my records?
No. Examples show structure and level of detail, and the content has to be yours. Copied text that does not match what happened in the session is a record-keeping problem, not a shortcut.
Does a telehealth session need a different SOAP format?
The format is the same. The content needs a few extra facts: that you confirmed the client's identity, that their environment was private, that consent was obtained including for any AI scribe, and any technical issue that affected the session.
How long do I have to keep clinical notes?
Retention periods are set by your National Board's requirements and by state, territory or Commonwealth health records legislation, which differ by jurisdiction. Ahpra's Managing health records page links to the relevant sources.