What did the client report?
Record the client's account of symptoms and functioning, including relevant changes since the previous session.
Course 3 · SOAP Notes
Know what belongs in each part of a SOAP note.
Learn to organize session information in S/O/I/A/P order. Practice explaining your interventions and the client's response in relation to the treatment plan and medical necessity.
$37Self-paced course with worked examples, practice, and course resources
S · SubjectiveClient reports using breathing practice before two work meetings.
O · ObjectiveGAD-7: 12. Speech normal. Thought process organized.
I · InterventionsReviewed cognitive restructuring and rehearsed paced breathing.
A · AssessmentSymptoms remain present with measurable improvement from baseline 16.
P · PlanContinue current plan and practice before the next identified trigger.
Course roleDemonstrates
Is this a good fit?
This training is for…
Therapists who write SOAP notes and want to feel less uncertain about what belongs in each section.
Study at your own pace in Mini Course Generator. Download the PDFs from Google Drive to use alongside the lessons.
- You spend longer on notes because you're deciding what to include.
- You want to distinguish the client's report from your clinical assessment.
- You need help describing the intervention you delivered and the client's response.
- You want your session notes to show how the work relates to treatment goals.
A session note example
Decide where each session detail belongs.
Scroll through this fictional session to see which details belong in each S/O/I/A/P section.
What did the clinician observe or measure?
Document what you observed or measured, including mental-status findings. Reserve your clinical interpretation for Assessment.
What did the clinician deliver?
Document the techniques you used during this session. Planned interventions belong in the treatment plan; this section records what you delivered.
What does the session evidence mean?
Explain what the session findings mean for the diagnosis and progress toward goals. Include relevant barriers and the rationale for continued treatment.
What happens from here?
Document the next steps in treatment, including any changes to frequency, referrals, safety monitoring, homework, or the next session's focus.
used breathing before meetings
GAD-7: 12
rehearsed paced breathing
improved from baseline 16
practice before next trigger
SClient reports using breathing practice before two work meetings and somewhat improved follow-through.
OGAD-7: 12. Anxious mood; congruent affect; organized thought process.
IReviewed cognitive restructuring and rehearsed paced breathing for a specific workplace trigger.
AClient continues to meet criteria for F41.1 with measurable improvement from the intake score of 16.
PContinue current plan. Client will practice before the next identified trigger and review response next session.
The review test
Can the note account for this date of service?
Review the client's report and your observations alongside the intervention you delivered. Explain the response and why continued care is indicated.
What changed since the last session?
Compare the client's report and current measures with previous sessions.
What was observed and delivered?
Describe your observations and the specific techniques you used.
What is the clinical interpretation?
Explain what the findings mean for progress and any barriers to treatment, including the current rationale for care.
How does the plan continue?
State what you and the client will do next in relation to the treatment goals.
Inside the course
You'll learn…
The course begins with medical necessity and the Golden Thread, then teaches the S/O/I/A/P sequence and administrative completeness.
Medical necessity and the Golden Thread
Understand how session documentation relates to the assessment, treatment goals, and current need for care.
Subjective
Select the client's reported symptoms and changes in functioning that are relevant to the session.
Objective
Document the 11-domain MSE and standardized measures as evidence, without premature synthesis.
Interventions
Describe the techniques you delivered and their relationship to the treatment plan.
Assessment
Use the seven-field structure for diagnosis, progress, barriers, strengths, prognosis, medical necessity, and disclaimer.
Plan
Record the next steps in treatment and any changes to the existing plan.
Administrative completeness
Finish the session information and documentation details that support the note.
Complex scenarios
Apply the note structure to more complex clinical situations.
Inside the online course
Try the concepts as you learn them.
These screenshots show activities from the SOAP Notes course. You can sort examples and check your understanding before practicing a full note.
A look at the actual workbook
See what you'll work with.
These are pages from the SOAP Notes Workbook PDF included with this course. Select a page to take a closer look.
Work with it
Handouts included
Use the workbook to draft each section and compare your responses with the completed examples.
- SOAP Notes WorkbookWriting practice and model responses.
- Gold Standard SOAP template and completed exampleThe fuller reference version.
- Good Enough SOAP template and completed exampleA more concise working version.
- SOAP Golden Thread self-auditReview the relationship between the note and treatment plan.
- SOAP session checklistA reference for reviewing your session documentation.
- Bonus: SOAP Notes AI PromptFor use with your own clinical judgment and applicable privacy requirements.
Progress over time
Compare progress across sessions.
Follow the fictional client Marcus T. across several sessions. Compare his scores and functioning, and see how the clinician documents the response to treatment.
GAD-7: 16
The intake score provides a baseline for comparing later scores.
GAD-7: 12
At session 8, the score is lower than at intake. The note also documents the intervention and the client's response.
Clinical assessment of progress
Consider symptoms and functioning alongside the score when deciding what to recommend next.
Choose what fits
Choose SOAP Notes or the full series.
This course focuses on documentation at the session level. The bundle includes the assessment and plan the note depends on, plus the closure documents that complete the episode of care.
03→
04→
07→
SOAP Notes · $37
The complete session-documentation course and its current learning resources.
From Intake to Discharge · $97
All four courses plus the complete Templates and Examples pack.
Templates and Examples · $47
SOAP and six other document templates with completed models, without the training.
Write it Right: SOAP Notes
Get help with the notes you write every week.
Use the worked examples to review a recent note. Have you explained how the client responded to the intervention?