Headings
Subjective · Objective · Assessment · Plan
When to use it
SOAP is the default progress note when your notes are read by physicians, insurers or a shared record. It splits what the client reports from what you observe and measure, which suits telehealth follow-ups and visits with a symptom scale. Choose it over DAP when you want observations and scores kept apart from the client’s own account.
Example
Fictional example
Subjective
A.M., 29, seen by telehealth for depression follow-up. Reports sleeping better since keeping a fixed wake time. Still skipping lunch and avoiding friends. Says work feels “flat but doable.”
Objective
On camera from her apartment, dressed, hair washed. Speech slow but clear. Affect constricted, brightened when discussing her dog. PHQ-9 is 14, down from 19 four weeks ago.
Assessment
Major depressive disorder, single episode, moderate. Improving with behavioral activation. Social withdrawal remains the main barrier. No safety concerns reported.
Plan
Continue weekly sessions. Schedule one social contact and three planned lunches this week. Repeat PHQ-9 in two weeks.