A SOAP note is a structured clinical documentation format with four sections: Subjective, Objective, Assessment and Plan. Clinicians use it to record a client encounter consistently — what the client reports, what the clinician observes, their clinical interpretation, and the next steps. It keeps notes organised, defensible and easy for other practitioners to follow.
What are SOAP notes?
SOAP notes are a way of structuring a clinical note so every encounter is documented in the same logical order. The acronym stands for Subjective, Objective, Assessment and Plan. The format grew out of the problem-oriented medical record developed by Dr Lawrence Weed in the 1960s and is now used across medicine, psychology, allied health and nursing (StatPearls, National Library of Medicine).
The value of SOAP is consistency. When every note moves from the client's own account, to observable data, to your clinical reasoning, to the plan, anyone reading the file — a supervisor, a covering clinician, an auditor — can follow the thinking. That structure also supports the accurate, contemporaneous record-keeping that registered practitioners are expected to maintain under their Board's standards, such as the Psychology Board of Australia under AHPRA.
SOAP is one of several note formats. If you are weighing your options, our guide comparing the types of clinical notes — SOAP, BIRP and DAP sets them side by side.
What does each part of a SOAP note mean?
Each letter is a distinct section with a clear job. Keeping them separate is what stops a note becoming an unstructured wall of text.
Subjective
The Subjective section captures what the client reports in their own words — their presenting concerns, symptoms, history and experience since the last session. In mental health this includes mood, sleep, appetite, stressors and how the client describes their week. It is the client's perspective, not yet your interpretation. Direct quotes can be useful here for significant statements.
Objective
The Objective section records what you observe and measure — factual, verifiable information. In a therapy context this covers presentation and mental state observations (appearance, affect, speech, engagement), risk indicators, and any standardised assessment scores administered in session. The distinction from Subjective is important: Objective is what you saw and measured, not what the client told you.
Assessment
The Assessment section is your clinical reasoning — how you interpret the Subjective and Objective information together. It may include your formulation, progress against goals, any change in diagnosis or risk, and your professional judgement about what the data means. This is the section that demonstrates clinical thinking, so it should connect the evidence above to your conclusions rather than simply restating them.
Plan
The Plan section sets out what happens next: interventions used and planned, homework or between-session tasks, referrals, safety planning, medication considerations (where relevant), and the timing of the next appointment. A good Plan is specific enough that you — or another clinician — could act on it without guessing.
What does a SOAP note look like?
Here is a short, illustrative example for a mental-health session (details are hypothetical, for format only):
Notice how each section stays in its lane, the Assessment ties the data to a judgement, and the Plan is actionable.
How do you write an effective SOAP note?
A few habits separate a note that protects you and helps the client from one that just fills the field. The goal is a record that is quick to write, easy to read later, and clear enough to stand up if it is ever reviewed:
- Keep sections distinct. Don't let interpretation leak into Subjective or Objective. If it's your judgement, it belongs in Assessment.
- Be specific and measurable. "Improved mood" is weaker than "reports mood 6/10, up from 3/10; GAD-7 down 5 points." Measurable data shows progress over time.
- Write it to be read by someone else. Assume a covering clinician or supervisor may rely on it. Avoid private shorthand that only you understand.
- Document risk clearly. Note what you assessed and what you did about it, even when risk is absent ("no suicidal ideation reported or observed").
- Write contemporaneously. Complete notes as close to the session as possible, while detail is accurate — a professional record-keeping expectation, not just good practice.
This is also where documentation tools help. An AI scribe can draft a structured SOAP note from a session so the clinician reviews and finalises rather than writing from a blank page — with the clinician approving every note before it is filed. PractaLuma is AI-native practice management software for Australian mental-health practices, built so clinical notes support this workflow rather than slowing it down. For a broader look at documentation formats, see our guide to writing effective progress notes.
SOAP vs DAP vs BIRP — which should you use?
There is no single correct format; the best choice depends on your discipline, setting and what your records need to demonstrate. SOAP is strong for medical and allied-health encounters where the Subjective/Objective split matters. DAP (Data, Assessment, Plan) collapses S and O into one "Data" section and suits talk-therapy notes where that distinction is less useful. BIRP (Behaviour, Intervention, Response, Plan) foregrounds the intervention and the client's response, which fits many mental-health and case-management contexts. Many practitioners use SOAP as their default and adapt — for example, our walk-through of paediatric SOAP notes for speech therapy shows the format applied to allied-health goals. Whatever you choose, applying it consistently matters more than the acronym itself.
Frequently asked questions
What does SOAP stand for? SOAP stands for Subjective, Objective, Assessment and Plan — the four sections of the note, written in that order.
What is the difference between the Subjective and Objective sections? Subjective is what the client reports in their own words (symptoms, experience, history). Objective is what the clinician observes and measures (presentation, mental state observations, assessment scores). Subjective is the client's account; Objective is verifiable data.
Are SOAP notes used in mental health? Yes. Psychologists, counsellors and psychotherapists use SOAP notes, though some prefer DAP or BIRP for talk therapy. The Objective section typically captures mental state observations and standardised assessment scores rather than physical findings.
How long should a SOAP note be? Long enough to be clinically useful and defensible, but no longer. Most session notes are a few sentences per section. Prioritise specific, measurable detail — especially in Assessment and Plan — over volume.
Do SOAP notes need to be stored securely? Yes. Clinical notes contain sensitive health information and must be handled under the Australian Privacy Principles, with appropriate access controls, encryption and audit logging in whatever system holds them.