How Do You Write SOAP Notes for a Mental Health Patient?

SOAP notes for a mental health patient begin with the client’s summary of the current issue, which is followed by objective observations that support the summary, explains the United Nations. The counselor adds assessments about the client, the specific session and the overall problem, as well as future plans.

For the “S” segment, the client’s subjective statement is typically a direct quote that describes the purpose of the session, according to the UN. While these conclusions are usually placed within quotation marks, counselors bracket their own comments to indicate they are not from the client.

“O” stands for objective information, the UN says. The counselor collects data on the client’s affect, body language and verbalizations to provide evidence for the subjective statement. In the assessment section, the “A” portion, the counselor offers professional judgements, opinions and interpretations based on the information gathered in the S and O sections.

Finally, “P” stands for the counselor’s and client’s plans, states the UN. Counselors list future interventions and actions they plan to take. They also identify any activities that clients should do outside of the sessions.

SOAP notes typically focus on clients’ current care rather than on broad information required for other mental health documentation, the Collaborative Family Healthcare Association informs. Counselors develop these notes for individual, group or family sessions, as well as meetings with other professionals, the UN. advises.