How to Actually Deal with SOAP Notes For Counselling (With Examples)

How to Actually Deal with SOAP Notes (Without Losing Your Mind)

Okay, let's be real for a second. You're probably reading this at some ungodly hour, staring at your computer screen, trying to remember if Mrs. Patterson was the one who cried about her divorce or if that was the Tuesday client who had the panic attack in your office.

I get it. I've been there—sitting in my car in the parking lot at 8 PM, laptop balanced on my steering wheel because I couldn't face going home without finishing my notes. It sucks.

But here's the thing: documentation doesn't have to be this soul-crushing nightmare that makes you question why you didn't just become a teacher like your mom wanted.

Why SOAP Notes Even Exist (And Why We're Stuck With Them)

Imagine it's six months from now, and you're sitting across from a lawyer who wants to know exactly what interventions you used with a client back in March.

Or maybe you're trying to hand off a client to another therapist and you need to explain three years of progress in a way that actually makes sense. Fun times, right?

SOAP notes came from this doctor named Lawrence Weed back in the 60s. The guy basically looked at medical charts and said, "This is chaos—we need a system."

And honestly? He wasn't wrong. The four-part thing (Subjective, Objective, Assessment, Plan) actually mirrors how we naturally think through cases anyway.

We listen to what clients tell us, we observe what's happening, we figure out what it means, and then we decide what to do next.

My Two Strategies for Not Dying of Documentation

Look, I've tried every system under the sun. Color-coded templates, voice recordings, sticky notes all over my desk like some kind of therapy detective.

Most of it was garbage. But I've found two approaches that actually work without making you hate your life.

Strategy #1: Let Soapnotes.doctor Do the Heavy Lifting

Full disclosure—I'm totally biased here because I helped create SOAP Notes Doctor. But hear me out before you roll your eyes.

Here's how it works: You hit record when your session starts. Soapnotes.doctor listens to everything—not just what you and your client say, but how they say it. Then it automatically spits out a proper SOAP note in about two minutes.

The system is HIPAA compliant and the recordings get deleted immediately after processing.

Millitary Grade encryption.

Plus, you review everything.

The best part? It catches stuff you'd totally forget. Like when your client used that specific phrase about feeling "trapped in amber" when describing their depression.

Or when they did that nervous laugh right before admitting they'd been having suicidal thoughts. Those details matter, and let's be honest—after seeing six clients in a row, your brain isn't exactly a steel trap.

Strategy #2: The Three-Layer Thing (For the Control Freaks)

Maybe you're one of those people who likes doing everything manually. That's fine—I respect that.

You probably also balance your checkbook by hand and refuse to use GPS. More power to you.

If you're going the manual route, here's the system that'll save your sanity:

Layer 1: Set Up Your Template Before Anyone Shows Up

Stop starting from a blank page every single time. It's like trying to cook dinner without knowing what's in your fridge. Create a basic framework and stick with it:

Subjective: "Client reports feeling [insert mood] since last session. Main issue today: [the thing they spent 30 minutes talking about]. Quote that made me go 'hmm': [their exact words]."

Objective: Just make a simple checklist. Did they make eye contact? Were they fidgety? Did they talk at their normal speed or sound like they'd had six espressos?

Assessment: What's actually going on here? Are they getting better, worse, or stuck in the same patterns? Any red flags?

Layer 2: Develop Your Own Shorthand (But Make It Make Sense)

This is where people usually screw up. They try to write novels during sessions and end up missing half the conversation because they're scribbling away like court stenographers.

Create abbreviations that actually work for you. Mine look like this:

• "Anx++" means high anxiety with visible symptoms
• "Coping↑" means they're actually using the strategies we talked about
• "Fam → deflect" means they changed the subject every time we got near family stuff

The key is being consistent. Don't use "Anx" one week and "anxiety" the next.

Pick a system and stick with it, or you'll be googling your own abbreviations six months later.

Layer 3: The Five-Minute Rule (This Is Where Most People Fail)

As soon as your client walks out—literally, while their perfume is still lingering in the air—sit down and expand your chicken scratch into real sentences.

Not after lunch. Not after your next client. Not at the end of the day when you're questioning all your life choices. Right. Now.

Five to seven minutes max. Turn your shorthand into something a human can read.

Add your clinical thinking. Connect the dots between what happened and your treatment goals.

Make it clear that you're not just throwing darts at a board here—you've got a plan and reasons for everything.

Your Assessment section should sound like it came from an actual licensed professional, not someone who just googled "how to help sad people."

And please, for the love of all that's holy, don't just write "continue therapy" in your Plan section. Be specific. What are you going to do differently next week? What's the next milestone you're working toward?

The Bottom Line

Look, I'm not going to lie and say documentation will ever be the fun part of your job.

But it doesn't have to be the thing that drives you to drink or switch careers.

Whether you go with the AI route or stick with the manual approach, the key is finding something you can actually sustain.

Because a system that works 80% of the time is infinitely better than a perfect system you abandon after three weeks.

And remember—good notes aren't just about covering your ass legally (though they do that too).

They're about being a better therapist. When you can look back at six months of clear, detailed notes and see patterns you missed in the moment, that's when this whole documentation thing starts to make sense.

Now stop procrastinating and go finish your notes. Your future self will thank you.