How to write a SOAP note (with UK therapy examples)

A SOAP note organises a session record into four sections — Subjective, Objective, Assessment, Plan — so that anyone reading it later (including future you) can follow the clinical picture quickly. For UK private-practice therapists it's one of the most widely used formats, and a solid SOAP note will satisfy most insurers, supervisors, and safeguarding reviewers.

What each section actually means in a therapy context

The SOAP format comes from medicine, so the labels need a little translation for talking-therapy work.

Subjective is what the client brings: their own words, reported mood, what they say has happened since the last session. Quote directly where it adds clinical weight — "I managed the presentation but felt sick the whole time" tells you more than "client reported anxiety at work". Include anything the client identifies as their focus for today.

Objective is your observable data: affect, presentation, engagement, any formal measures. In therapy this is narrower than in medicine. You might note "flat affect, maintained intermittent eye contact, speech slowed compared with previous session" or record a PHQ-9 score if you collected one. Stick to what you actually observed, not inference.

Assessment is your clinical interpretation — the professional judgement that makes the note yours. How does today's presentation relate to the formulation? Is there progress, deterioration, or something new to consider? This is where modality language belongs: a CBT practitioner might note a shift in a core belief; a person-centred therapist might comment on the quality of the therapeutic relationship or a moment of self-acceptance.

Plan records what happens next: homework agreed, techniques to revisit, referrals to consider, risk actions taken, and the date of the next session. Be specific. "Agreed to complete thought record on Tuesday morning before the team meeting" is more useful than "behavioural experiment discussed".

A worked example: CBT session for health anxiety

S: Client reports a difficult fortnight following a GP appointment where a routine blood test was flagged for repeat. States "I know it's probably nothing but I can't stop Googling". Reassurance-seeking from partner has increased. Rates anxiety 7/10 this week, up from 5/10 last session.

O: Visibly tense on arrival, settled during check-in. GAD-7 score 14 (moderate), up from 11 at last administration three weeks ago. Engaged well with Socratic questioning; able to identify reassurance-seeking as a maintaining behaviour when prompted.

A: Spike in anxiety consistent with a concrete health trigger rather than general deterioration. Client demonstrates good insight into the maintenance cycle but can't currently tolerate uncertainty without seeking reassurance. Formulation remains relevant; today's material provides a concrete in-session example to draw on. No safeguarding concerns. Risk: low.

P: Introduced postponing reassurance-seeking by 30 minutes, recording urge intensity before and after. Client to complete thought record on at least two occasions this week, focusing on probability overestimation. Discussed rationale for not Googling symptoms. Review GAD-7 at next session. Next appointment: [date].

A worked example: person-centred session for low self-worth

S: Client arrived saying she had "a strange week — not bad, just different". Described a moment at a family dinner where she chose not to apologise for expressing an opinion. Noted she felt uncomfortable but did not retract the comment. Rates mood 6/10, up from 4/10.

O: Warmer presentation than recent sessions; initiated conversation rather than waiting. Affect congruent with content. No formal measure administered this session (next PHQ-9 due in two weeks).

A: The dinner account appears to represent a meaningful shift in self-advocacy, which the client herself identified as significant. The discomfort she named suggests it isn't yet integrated — she's aware of the change but hasn't fully made sense of it. The therapeutic relationship felt more collaborative today; less pulling-back than in earlier sessions.

P: Return to the dinner moment next session if the client wishes to. No homework set — client expressed preference to let the week unfold without a task. Next appointment: [date]. No concerns.

Common mistakes UK therapists make with SOAP notes

Mixing inference into Objective. Writing "client appeared depressed" in the O section is an assessment, not an observation. Save it for the A section; in O, describe what you saw.

Vague Plans. "Continue CBT work" is not a plan. Name the technique, the agreed action, and who is doing what before the next session.

Omitting risk, even when low. A brief "no safeguarding concerns; risk assessed as low" protects you and creates an auditable record. Leaving it blank looks like it wasn't considered.

Over-long Subjective sections. The S section is a clinical summary, not a transcript. Two to four sentences is usually enough.

One honest limitation of the SOAP format

SOAP was designed for episodic medical encounters and can feel reductive for relational or process-oriented work. Person-centred or psychodynamic practitioners may find the Assessment section pulls them towards a more diagnostic frame than their modality warrants. Some therapists prefer DAP (Data, Assessment, Plan) or PIE (Presentation, Intervention, Evaluation) for exactly this reason. SOAP is widely recognised and legally defensible, but it isn't the only defensible format — the right note is one you'll write consistently and that reflects your clinical thinking accurately.

Practical tips for writing SOAP notes efficiently

• Write within 24 hours while the session is fresh; waiting until the end of the week turns the Subjective section into a reconstruction.
• Keep a shorthand for recurring themes (e.g. "RSB" for reassurance-seeking behaviour), expanding in full on first use in any given note.
• If you use outcome measures, link the score to the clinical picture in the A section rather than listing the number alone.
• Review your notes periodically in supervision — they're a useful mirror for your clinical thinking, not just a compliance exercise.

Where Sorca fits

If you record sessions (with client consent), Sorca's AI clinical scribe can draft a SOAP note from the transcript in your modality — CBT, person-centred, psychodynamic, and others. SOAP is one of eight supported formats (SOAP, BIRP, DAP, FIRP, GIRP, PIE, BASE, and group notes), so if SOAP isn't the right fit for a particular client, you're not locked in. Audio is transcribed in the browser and never stored; the transcript is then processed in memory server-side and discarded once the draft is generated. Nothing enters a client record until you review and save it (see how we handle data).

One practical consideration: Sorca requires session recording and explicit client consent before transcription, and every draft needs clinician review before it's saved — it's a drafting aid, not a substitute for your clinical judgement.

You can try Sorca free for three days — no card required — at sorca.life.