How I Approach SOAP Notes for Mental Health

SOAP Notes for Mental Health: A Complete Guide

If you're reading this at 9 PM with a stack of unfinished SOAP notes beside your cold coffee, I see you.

Mental health professionals didn't sign up to become part-time data entry specialists, yet here we are in a world where documentation can feel as demanding as the therapy itself.

As the founder of soapnotes.doctor, I've heard this frustration from hundreds of clinicians.

The good news? SOAP notes don't have to be your nemesis.

Quick tip: I fixed soap notes. You can too. Head over soapnotes.com and use the record button. Save the session when you're done. You have an industry-standard soap in about 1-3 minutes processing time. HIPAA compliant.

SOAP Notes In a Jiffy

When someone first told you about SOAP notes during your training, you probably thought, "Great, another acronym to memorize."

Created by Dr. Lawrence Weed in the late 1960s, SOAP notes emerged from an infallible observation: medical records were a mess.

Physicians were writing scattered, inconsistent notes that made it nearly impossible to track patient progress or communicate effectively with colleagues.

Weed's solution was straightforward—create a standard format that would ensure every important piece of information had a place.

What Exactly is a SOAP Note?

It's a structured way of documenting clinical encounters that breaks down into four essential components that I like to think of like chapters in a story:

Subjective (S): This is your client's story in their words. What brought them in today? How are they feeling? What's their perspective on their symptoms or situation? Think of this as the "according to the client" section.

Objective (O): Here's where you put on your clinical observer hat. What did you notice about their appearance, behavior, mood, or speech? Any test results or measurable data? This section is all about facts you can see, hear, or measure—no interpretations yet.

Assessment (A): Now you get to be the detective. Based on what your client shared and what you observed, what's your clinical impression? This might include diagnoses, symptom severity, progress toward goals, or areas of concern.

Plan (P): Finally, the action items. What's your therapeutic game plan? This covers everything from intervention strategies and homework assignments to medication adjustments and follow-up scheduling.

The reason SOAP notes have stuck around for over half a century is because they work.

How I Navigate SOAP Notes for Mental Health: Two Game-Changing Approaches

Here's the truth: there's no universal "best" way to handle SOAP notes.

What matters is finding the approach that fits your practice style, your client load, and honestly, your tolerance for repetitive tasks.

Let me break down both approaches so you can decide which path makes sense for your sanity and your practice.

Approach 1: Let Soapnotes.doctor Handle The Heavy Lifting (My Personal Favorite)

I'll be upfront.

This is the approach that gets me genuinely excited because it's literally why I built SOAP Notes Doctor.

But before you roll your eyes at the founder pitch, hear me out on why this method has become my go-to recommendation for overwhelmed clinicians.

The concept is beautifully simple.

During Your Session:

You simply hit record on the SOAP Notes Doctor app and focus entirely on your client.

No splitting attention between listening and note-taking, no mental gymnastics trying to remember exact phrases while staying present.

You get to focus, finally.

After Your Session:

Soapnotes.doctor transcribes your entire session, automatically identifies key clinical information, and formats everything into a professional SOAP note structure.

What used to take 30-45 minutes of post-session writing now takes about 2-3 minutes of review and customization.

Why I'm Obsessed With This Approach:

First, it eliminates the documentation backlog that kills so many therapists' work-life balance.

Clinicians don't have to burn out because of paperwork.

When your SOAP notes are essentially done by the time your client walks out the door, you actually get to leave work at work.

Second, the quality is consistently better.

When you're not trying to remember what happened three hours ago or reconstructing conversations from cryptic bullet points, your notes capture the nuances that actually matter for treatment planning.

Soapnotes.doctor remembers things you might forget—specific phrases your client used, behavioral observations, even the emotional tone of different parts of the session.

Third, our Tailorr feature gives you complete control over formatting and style.

You can add custom tags, modify sections according to your preferences, and maintain consistency across all your documentation.

Approach 2: Master the Art of Strategic Manual Documentation

Now, if you're the type of person who prefers keeping things old-school, let me share what I've learned from my experience in the field.

It's a 3 layer approach.

Layer 1 — Pre-Visit Template Setup

Have a mental-health focused template ready before the patient arrives.

A consistent framework keeps you from thinking from scratch every time.

Core elements to include:

• Chief complaint: short template line to capture reason for visit.

  • Example: Chief complaint: [duration] of [primary symptom] (e.g., 6 weeks low mood, increased worry)

• History of Present Illness prompts: onset, course, triggers, impact on daily life, prior treatments.

• Symptom checklist: mood, anxiety, sleep, appetite, energy, concentration, psychosis, mania, substance use, suicidality, homicidality.

• Risk assessment: SI/HI presence, plan, intent, means, protective factors, last self-harm.

• Collateral & functioning: living situation, supports, work/education, ADLs/IADLs.

• Medications & medical history: current psych meds, medical conditions, allergies.

• Mental Status Exam (MSE) quick fields: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment.

• Rating scales: PHQ-9, GAD-7, C-SSRS, or others — space to insert scores.

• Disposition & plan checklist: safety plan, meds change, therapy referral, labs, follow-up interval.

Keep the template short and scannable so you can tick boxes and insert short notes.

Layer 2 — A Shorthand System

Don't try to write full paragraphs during the session.

Use short codes and abbreviations you'll always expand later.

Examples (shorthand → how you'll read it later):

• PHQ9 15 → PHQ-9 score 15 (moderate depression).
• GAD7 8 → GAD-7 score 8 (mild–moderate anxiety).
• SI: passive, no plan → Denies active suicidal intent; reports passive wish to be dead; no plan or intent.
• AH x / AH - → Auditory hallucinations denied.
• Sleep: SOL 60, TST 4-5h → Sleep onset ~60 minutes; total sleep time 4–5 hours.
• Funct: ADL ok, work ↓ → ADLs intact; work performance decreased due to concentration and fatigue.
• Med: fluox cont, consider add SSRI → Current medication: fluoxetine continued; discuss consideration of medication adjustment.
• SP given + collat ok → Safety plan provided; patient consented to contact collateral if needed.

Make your shorthand consistent and unambiguous.

Use numbers for scores, short labels for common concepts (SI, HI, AH, VH, MSE).

Layer 3 — The Post-Visit Polish

Right after the visit (3–5 minutes), expand your shorthand into clear, complete sentences.

Add clinical reasoning, differential diagnoses, and a concrete plan.

What to include during polish:

• Subjective (S): brief patient quote + current scores and key symptoms.
• Objective (O): MSE findings, observed behavior, vitals if relevant.
• Assessment (A): working diagnosis, severity, risk summary, brief rationale.
• Plan (P): interventions, safety measures, meds/therapy actions, follow-up timing, measurable goals.

Example — Shorthand First

S: 29F, 6wk ↓mood, PHQ9 16, SI passive no plan, sleep 4-5h, appetite ↓, work ↓
O: cooperative, speech NL, mood depressed, affect constricted, thoughts linear, no AH/VH, cog intact
A: MDD, moderate. Passive SI + safety factors (spouse support). Rule out substance-induced mood.
P: Safety plan given; CBT referral qwk; consider SSRI change after consent; f/u 2 wks; repeat PHQ9 at f/u.

Expanded SOAP (Ready to File)

S: Patient is a 29-year-old female reporting a 6-week history of low mood, decreased energy, poor sleep (4–5 hours/night), and reduced appetite. PHQ-9 = 16. She reports passive thoughts of not wanting to wake up but denies active suicidal ideation, plan, intent, or access to means. Work performance has declined over the past month.

O: Alert and cooperative. Speech normal in rate and volume. Mood reported as "down"; affect constricted and congruent with mood. Thought process linear and goal-directed. Denies hallucinations or delusions. Cognition grossly intact. Insight partial; judgment intact.

A: Major depressive disorder, moderate severity, supported by symptom duration, PHQ-9 score, and functional impairment. Passive suicidal ideation without plan or intent; protective factors include spouse support and willingness to engage in treatment. Differential includes adjustment disorder with depressed mood and substance-induced mood disorder (substance use screens discussed).

P: Reviewed safety plan and provided written copy. Patient agreed to contact emergency services or crisis line if SI escalates. Begin weekly CBT referral (placed) and schedule psychiatry med review to consider SSRI adjustment; patient prefers to discuss med options at next visit. Follow up in 2 weeks. Repeat PHQ-9 at next visit. Documented informed consent for treatment and for contacting collateral if needed.