Clinical and counseling psychologists use SOAP notes for therapy session documentation, assessment feedback sessions, and ongoing care following a psychological evaluation. The SOAP structure adapts well to the integration of testing, formulation, and psychotherapy that's distinctive to psychology practice.
This guide covers how psychologists document each SOAP section, where psychological test results and case formulation belong, and how SOAP notes differ from psychotherapy process notes.
Start Free TrialSOAP is broadly accepted in psychology practice — outpatient therapy, integrated primary care, hospitals, and private practice. The structural separation works well for psychology specifically because test results, observation, and clinical interpretation each have a clear home.
Test scores live in Objective. Score interpretation and case formulation live in Assessment. Psychotherapy interventions and follow-up plans live in Plan. That separation supports both insurance review and continuity of care across providers.
Subjective captures what the client reports — symptoms, mood, recent events, between-session experience, and any self-report content from screeners or symptom inventories. For psychologists doing CBT, ACT, or other structured modalities, this is often where homework completion and skill use get documented as the client describes them.
Objective in a psychology SOAP note holds three categories of data: mental status exam findings, standardized test or screener scores, and any other observable session content (engagement, attendance, behavior).
Mental status exam — appearance, behavior, mood, affect, thought process, cognition, insight
Symptom inventories and screeners — PHQ-9, GAD-7, PCL-5, Beck Depression Inventory, OCI-R
Outcome monitoring measures — ORS/SRS, OQ-45, when used in session
Test-related observation when administering or reviewing assessment results
Keep this section data-only. Score interpretation belongs in Assessment.
Assessment is where psychology training shows. The section integrates Subjective and Objective into a clinical formulation: working diagnosis, case conceptualization (cognitive, behavioral, dynamic, integrative — whichever framework you use), progress against treatment goals, and risk formulation when relevant.
You don't need to restate the full case formulation every session. A one or two sentence update is enough for routine sessions: "Consistent with working formulation — avoidance of perceived rejection driving social withdrawal; behavioral activation continues to produce small but reliable gains."
Plan documents specific psychotherapy interventions used in session, homework assigned, follow-up cadence, and any treatment plan adjustments. Name the technique, not just the modality — "exposure hierarchy work targeting public-speaking avoidance" is stronger than "exposure therapy."
For sessions following a psychological evaluation, Plan can also reference assessment-driven recommendations: re-administering measures at a planned interval, referrals based on assessment findings, or treatment plan revisions stemming from the evaluation.
HIPAA distinguishes between the clinical record and psychotherapy process notes (sometimes called private process notes). A SOAP note is part of the clinical record — used for billing, coordination of care, and supervision. A process note is the psychologist's private clinical thinking, kept separately, with stricter HIPAA protections.
For most psychology practices, SOAP is the session note that lives in the chart, and process notes are an optional separate tool. Don't conflate them: detailed clinical reasoning that you want to keep private should live in process notes, not in SOAP.
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Yes. Clinical and counseling psychologists (Ph.D., Psy.D.) commonly use SOAP notes for therapy session documentation. SOAP also adapts well to psychological testing report-out sessions and ongoing therapy following an assessment battery.
Standardized test results, screener scores (PHQ-9, GAD-7, PCL-5, Beck inventories), and any quantitative data belong in Objective. Test interpretation — what the scores mean clinically, how they integrate with the broader formulation — belongs in Assessment. This separation keeps the score data distinct from the clinical reasoning.
A SOAP note is part of the clinical record — it documents the session in a way that supports billing, supervision, and continuity of care. A psychotherapy process note (sometimes called a private process note) is a separate record kept for the psychologist's own clinical thinking and is not part of the clinical record. Process notes have different HIPAA protections than SOAP notes.
Some form of formulation should appear in Assessment — even a brief one-line update to the formulation. You don't need to restate the full case formulation every session. What matters is that the Assessment section ties the current session's content back to the working formulation and the treatment plan.
Partially. SOAP works well for assessment feedback sessions and for ongoing therapy. For full assessment battery sessions (administering and scoring tests), most psychologists use a separate assessment report format rather than SOAP. The integrated psychological evaluation report is its own document.
AfterSession produces full SOAP notes that integrate test scores, MSE findings, and case formulation — clinician reviews and approves every note.