A SOAP note template gives you four fixed headings, Subjective, Objective, Assessment and Plan, and a prompt for what belongs under each. Formatting matters as much as content: keep observation out of the Objective section, keep reasoning in the Assessment, write in the session or straight after, and make every entry legible to another practitioner.

Most clinicians learn what SOAP stands for in about ninety seconds, then spend years writing notes that are structurally correct but practically useless. The headings are the easy part. The hard part is knowing what phrasing belongs where, how much detail is enough, and what a note has to look like when someone else reads it: a colleague covering your caseload, an auditor, a court, or the client themselves. This guide is the formatting layer. For the underlying concepts, start with our complete guide to SOAP notes.

What does a SOAP note template look like?

Here is a discipline-neutral template you can copy into your record system and adapt. Every line is a prompt, not a mandatory field.

Session details: client identifier, date, start and finish time, session type (in person, telehealth, phone), attendees, clinician name and role.

S (Subjective)

Presenting concern in the client's own words, quoted where it carries clinical weight.
Changes reported since the last session: symptoms, sleep, function, medication, life events.
What the client, family or support worker reports about tasks or strategies set last time.
Risk information disclosed by the client.

O (Objective)

What you observed: presentation, affect, engagement, physical findings.
What you did: the intervention, activity or assessment used, described specifically enough to repeat.
What you measured: scores on standardised measures, counts, durations, levels of assistance, vital signs where relevant.
Anything documented from records or reports rather than reported in the room.

A (Assessment)

Your clinical reasoning: what the subjective and objective data taken together mean.
Progress against the treatment or care goals, stated in relation to a baseline.
Diagnosis or formulation status, including changes and differential possibilities.
Risk assessment and the reasoning behind your conclusion, not just the rating.

P (Plan)

What happens in the next session, and what the client will do between sessions.
Referrals, reviews, escalations and their timeframes.
Reports, letters or forms owed, and to whom.
Next appointment, and any contingency or safety plan.

How should each section be formatted?

Subjective: report, do not interpret

Write what was said, attributed to who said it. "Client reports sleeping four hours a night for the past fortnight" is subjective data. "Client is not coping" is a conclusion, and conclusions belong two sections down. Short direct quotes are the most defensible form of this section because they cannot be argued with later. Keep them short: a quoted sentence, not a quoted paragraph.

Where the information came from a third party, say so. "Partner reports two missed doses" and "client reports full adherence" can both be true, and a note that flattens them into one line loses the discrepancy that mattered.

Objective: measurable, repeatable, no adjectives

The Objective section is the one that fails audits. StatPearls, the standard clinical reference on the format, draws the line at symptoms versus signs: a patient's report of stomach pain is a symptom, while abdominal tenderness on palpation is an objective sign (StatPearls, SOAP Note). Everything you can see, count, time or score sits here.

Practical formatting rules:

Name the instrument and give the score with its scale, for example "PHQ-9: 14 (moderate), up from 11 on 12 June".
Describe the intervention specifically enough that a colleague could deliver it: "behavioural experiment on lift avoidance, two trials" beats "CBT".
Replace evaluative adjectives with the observation behind them. Not "poor engagement", but "declined two of three tasks, ended session eight minutes early".
Timestamps and durations belong here, not in your head.

Assessment: the reasoning, not a restatement

The Assessment section synthesises the subjective and objective findings to reach a conclusion. This is where you are permitted to interpret, and where most notes go quiet. A useful assessment answers three questions: what has changed since last time, why do you think it changed, and does the plan still hold. If it does not, say so here before the Plan says something different.

Write it so the reasoning survives without you. "Reduced avoidance behaviours consistent with graded exposure gains; sleep remains the maintaining factor" tells a reader what you thought and why. "Progressing well" tells them nothing they can act on.

Plan: assign an owner and a date

Every plan item should have a person attached and a timeframe. "Refer to GP" becomes "letter to GP re medication review, sent this week; review response at next session, 21 August". If it is not dated, it is not a plan, and a note without dated actions is very hard to defend when someone asks what you did about a risk you identified.

What formatting mistakes make SOAP notes fail?

Interpretation in the Objective section. The single most common one. "Client appeared anxious" is an inference; "client shifted position repeatedly, spoke rapidly, declined water" is the observation it rests on.
Copy-forward. Pasting last session's note and editing two words produces records that look identical across months. It is obvious to any reviewer and it destroys the value of the Assessment section, which exists to show change.
Abbreviations only you use. Discipline-standard abbreviations are fine. Personal shorthand fails the "understood by other practitioners" test.
Editing without a trail. If you need to correct a note, add a dated addendum rather than overwriting. Silent edits look worse than the original error.
Writing days later. Recall degrades and the record loses its contemporaneous character.
Language you would not defend to the client. Clients can request access to their own records, so write as if they will read it, because they may.

What do Australian record rules require of your SOAP notes?

Formatting is not only a quality question here. The Psychology Board of Australia's Code of conduct for psychologists, effective from 1 December 2025, sets out at section 8.5 that effective practice includes that you "keep accurate, up to date, factual, objective, legible and accessible records that report relevant details of the service provided in a form that can be understood by other practitioners and colleagues", that records are "sufficient to facilitate continuity of the service provided", and that you "make records at the time of events or as soon as possible afterwards" (Psychology Board of Australia, Code of conduct).

Read that list against the template above and the mapping is direct. "Factual, objective" is the Objective section. "Understood by other practitioners" is the abbreviation rule. "Sufficient to facilitate continuity" is why the Plan section needs owners and dates. "At the time of events or as soon as possible afterwards" is why the note is written before you leave the room, not on Friday.

The same section sets retention minimums: at least seven years since the last entry in an adult client's record, and for clients who were under 18 at the last entry, until after their 25th birthday. Other professions and jurisdictions have their own requirements, and state health records legislation applies on top, so check the rules for your registration and your state.

Two privacy principles also shape how notes should read. Under the Australian Privacy Principles, APP 10 requires an entity to take reasonable steps to ensure personal information is accurate, up to date and complete, and APP 12 governs access requests, including a requirement to give an individual access to the personal information held about them unless a specific exception applies (OAIC, Australian Privacy Principles quick reference). In practice, that is the argument for keeping speculation and any remark you would not say aloud out of the record.

How do you adapt the template to your discipline?

The four headings hold across health, but the weight of each section shifts. In occupational therapy the Objective section carries the note, because performance data is the evidence base for funding decisions: see our occupational therapy SOAP note examples. In counselling and psychotherapy the Assessment section does the heavy lifting and the Objective section is mostly mental state observations, which is why SOAP note templates for mental health counselling look different from a physiotherapy note.

SOAP is also not the only option. BIRP and DAP collapse the observation and interpretation steps differently, and for some caseloads they are a better fit; our comparison of clinical note types sets them side by side. If you are building your own version of any of these, our guide to creating and customising clinical note templates covers the process.

Should your SOAP template live in software?

A template in a Word document solves the structure problem and nothing else. You still retype the session details, still write the note after hours, and still have no way to see whether the Objective section is thin across your caseload.

A template built into your record system can prefill session details, keep headings consistent across every clinician, timestamp entries so the contemporaneous requirement is met by default, and hold the audit trail that makes an addendum defensible. PractaLuma is AI-native practice management software for Australian mental-health practices, and its clinical notes and AI scribe features draft the note into your own SOAP structure during the session, with the clinician reviewing and approving before anything is filed. You can see how it fits with the rest of the workspace on the features overview.

Frequently asked questions

How long should a SOAP note be? Long enough that a colleague picking up the file could continue care, and no longer. For a routine follow-up that is often 100 to 200 words. Complexity, risk and change drive length, not a target.

Can I put my clinical opinion in a SOAP note? Yes, in the Assessment section, with the reasoning attached. Opinion in the Subjective or Objective sections is the formatting error that causes most trouble later.

What do I do if I make a mistake in a note? Add a dated, signed addendum that states the correction. Do not overwrite or delete the original entry. Systems with an audit trail handle this for you.

Is SOAP better than DAP or BIRP? It depends on the work. SOAP suits disciplines with measurable, observable data. DAP and BIRP suit talk-based sessions where separating subjective from objective is artificial. Consistency across your practice matters more than the format you pick.

Do I have to write notes during the session? Not necessarily, but the record should be made at the time of events or as soon as possible afterwards. Same-day is the practical standard; a week later is not.

SOAP Note Template: How to Format Clinical Notes