How do I write the Subjective section of a SOAP note for behavioral health clients?

The Subjective (S) section of a SOAP note captures the client’s own report of their current symptoms, experiences, and concerns in their own words—or paraphrased by the clinician. This portion is crucial in behavioral health because it reflects the client’s internal state and perceived progress, providing context for clinical interpretation and treatment planning. What to Include in the Subjective Section: Presenting concerns or reason for the visit (e.g., increased anxiety, relationship conflict) Client-reported symptoms , severity, duration, and any changes since the last session Mood and affect descriptions as shared by the client (e.g., “I feel numb all the time”) Sleep, appetite, and energy levels if relevant Medication adherence and side effects (if applicable) Substance use updates Life events or stressors reported by the client Client’s insight into their issues or treatment progress Statements of intent or risk , such as suicidal ideation or safety concerns Quotes or paraphrased statements that highlight the client's emotional state Mental Health-Specific Examples: "Client reports feeling more depressed this week, stating, 'I just don't see the point of anything lately.'" "She reports frequent panic attacks, especially when driving, rating anxiety as a 7/10 today." "Client says he hasn’t been taking his medication regularly because 'it makes me feel like a zombie.'" "States she is sleeping only 3–4 hours per night and feels exhausted during the day." "Client reports an argument with his partner triggered feelings of abandonment and led to self-harming behavior." "Says he’s drinking more than usual: 'I’ve had a few beers every night just to calm down.'" Tips for Writing an Effective Subjective Section: Be concise but descriptive : Include only clinically relevant details. Use the client’s voice : Incorporate direct quotes when they reflect mood or thought patterns. Stick to observable or reported information : Save interpretations for the Assessment section. Note discrepancies : For example, “Client reports feeling fine but appears tearful and withdrawn.” A well-written Subjective section helps ensure your documentation reflects the client’s lived experience while supporting continuity of care and medical necessity for behavioral health services.

How detailed should the Objective section be in mental health SOAP notes?

In behavioral health, the Objective (O) section of a SOAP note includes observable, measurable, and clinically relevant information gathered by the clinician during the session. Unlike in medical settings where “objective” data might include vital signs or lab results, in mental health, this section focuses more on what you as the clinician can see, hear, or assess directly , even if it's not quantifiable in the traditional sense. What “Objective” Means in Behavioral Health: In this context, “objective” refers to your professional observations of the client’s: Appearance (e.g., disheveled, well-groomed, wearing appropriate clothing) Behavior (e.g., fidgeting, tearful, withdrawn, cooperative) Speech (e.g., rapid, pressured, slurred, soft, clear) Mood and affect (as observed, not self-reported) Thought processes (e.g., tangential, coherent, logical) Cognition and orientation (e.g., alert, oriented to person/place/time) Insight and judgment (as demonstrated in responses and decision-making) You may also include results from any standardized assessments (e.g., PHQ-9 scores) or mental status exams (MSE). How Detailed Should It Be? The level of detail should be clinically appropriate and relevant to the session’s focus , and sufficient to support your assessment and treatment decisions. Avoid overly vague descriptions, but also don’t include unnecessary detail that doesn't impact care. Example – Well-Detailed Objective Entry: Client appears disheveled and avoids eye contact. Speech is slow but coherent. Affect is flat and mood appears depressed. Thought process is logical but content is pessimistic. No psychotic symptoms observed. Oriented x4. PHQ-9 score today is 18 (moderately severe depression). Example – Minimal but Acceptable Objective Entry: Client presented on time, dressed appropriately. Affect appeared anxious; speech was pressured. No safety concerns observed. A strong Objective section complements the Subjective report and strengthens clinical documentation for progress tracking, supervision, and audits. Always focus on what you directly observed and link it to the client’s mental health status.

What are common mistakes clinicians make in SOAP note documentation?

SOAP notes are a critical part of behavioral health documentation, but even experienced clinicians can fall into common pitfalls that compromise the clarity, quality, or compliance of their notes. Here are some of the most frequent mistakes—and how to avoid them—along with mental health-specific examples. 1. Blending Subjective and Objective Information Mistake: Including personal observations in the Subjective section or reporting client statements as observations in the Objective section. Example: Incorrect: S: Client appeared depressed and avoided eye contact. Correct: S: Client reports feeling “hopeless” and “tired all the time.” O: Client avoided eye contact, appeared tearful, and moved slowly. 2. Using Vague, Generic Language Mistake: Writing notes like “client doing well” or “session went as planned” without specific clinical detail. Example: Incorrect: S: Client is feeling better. Correct: S: Client reports fewer intrusive thoughts and was able to go to the grocery store alone for the first time in weeks. 3. Failing to Demonstrate Medical Necessity Mistake: Not clearly documenting symptoms, functional impairments, or the rationale for continued treatment. Example: Incorrect: A: Client is stable. Correct: A: Client remains symptomatic with persistent anxiety impacting ability to work full-time. Progress is noted, but continued CBT is needed to address avoidance behaviors. 4. Over-Reliance on Copy-and-Paste Mistake: Duplicating prior notes without updating to reflect the current session. This can make it appear that no progress has occurred or that sessions are not individualized. Example: If every note says, “Client presents with anxiety and discusses coping skills,” it may raise red flags in audits or utilization reviews. 5. Including Irrelevant Personal Details Mistake: Adding anecdotes or personal stories that do not serve a clinical purpose. Example: Incorrect: Client talked for 20 minutes about their favorite movies. Better: Client used discussion of movies to illustrate difficulty with focus and anhedonia; stated, “I used to enjoy these, but now I feel numb watching them.” 6. Inadequate Follow-Up in the Plan Section Mistake: Failing to include next steps, goals, or homework. Example: Incorrect: P: Continue therapy. Correct: P: Continue weekly CBT sessions. Client will complete behavioral activation worksheet and track activities for review next session. 7. Ignoring Risk Documentation Mistake: Not documenting when a risk assessment was completed—or skipping it altogether. Example: Omission: No mention of suicidal ideation even though the client discussed feeling hopeless. Correct: Client denied suicidal ideation or plan. Safety plan reviewed and confirmed. Will reassess next session.

How can time be saved when documenting notes for large group therapy sessions?

Use a shared group summary at the top of each note to document details like topic, interventions, and group attendance—this only needs to be written once and duplicated across client notes. Then, add brief individualized content for each participant that speaks to their behavior, participation, and clinical progress. EHR systems like ICANotes streamline this by pushing a single session note into all relevant charts , reducing redundancy while maintaining compliance.

Is it necessary to write a separate note for every client in group therapy?

Yes. Each participant must have an individualized group therapy note in their medical record to establish medical necessity and support reimbursement. While the group-level summary can be duplicated, the client's observed mood, participation, progress toward goals, and next steps must be specific to their experience in the session.

How should clinicians document group and individual dynamics in a single note?

Start each note with a shared group synopsis—include session date, time, topic, number of participants, and interventions. Then, document how the client interacted with the group and how the group responded to them. Highlight any emotional, behavioral, or interpersonal dynamics that shaped the session from both directions: how the client influenced the group, and how the group influenced the client.

How should telehealth or hybrid group sessions be documented differently?

For virtual or hybrid sessions, include the delivery method (e.g., “Telehealth via Zoom”) in your group summary. Note any technical issues, disruptions, or limitations that may have impacted participation or clinical effectiveness. Be sure to document informed consent for telehealth, if required, and specify any differences in engagement or outcomes due to the format.

What interventions and outcomes are payers or insurers looking for in group notes?

Insurers typically expect documentation that demonstrates medical necessity, therapeutic intent, and measurable progress. Include specific interventions (e.g., CBT techniques, mindfulness exercises) used during the session and link them to treatment goals. Summarize how the client responded—did the intervention reinforce a skill, reduce a symptom, or move the client closer to a behavioral goal? Lack of detail or generalizations may lead to denied claims.