Mixing report and observation
Keep what the client reported distinct from what the therapist directly observed whenever the format calls for that distinction.
One of the most widely used formats for session notes — a clear structure, broadly applied across mental health care. Here's how it's built, section by section.
Requested AI draft · Therapist-owned Assessment and Plan · Separate save-to-record action
SOAP stands for Subjective, Objective, Assessment and Plan — four fixed sections that together form a compact, recognizable session note. The format originates in somatic care and has been widely adopted in mental health care because it separates what the client reports (subjective) from what the therapist observes and concludes (objective, assessment, plan).
SOAP works well when treatment follows a structured, goal-oriented course and you want to scan quickly what came up, what you noticed, and what the next step is. If you work in a more process-oriented way with an emphasis on progress toward a treatment goal, DAP or GIRP often fit better; if your client is working on concrete behavior and the response to it, BIRP is often the more logical choice. For EMDR sessions, use the separate EMDR note, with its own standardized fields.
What the client reports, in their own words or briefly summarized: what's been going on recently, how things are going, what they bring up themselves.
What you, as the therapist, observe during the session: posture, mood, speech pattern, engagement — observable behavior, not interpretation.
Your clinical read on how things are going: patterns you recognize, progress compared to earlier sessions, what stands out in the combination of S and O.
The next step: what the next session focuses on, any homework for the client, points to watch.
A fictional example — for illustration only, not based on a real client.
Draft — for illustration onlyS — Subjective
Client M. shares that work pressure has increased over the past two weeks and notices she's been working into the evenings. Says it's hard to stop on time.
O — Objective
Calm, coherent speech. Slightly tense posture when discussing work, visibly relaxes once the conversation shifts to the weekend.
A — Assessment
The pattern of difficulty setting boundaries at work continues, consistent with sessions 4 and 5. Client appears to be growing more aware of it herself.
P — Plan
Next session: practice stopping on time once, as homework. Watch for: how it feels to hold that boundary.
Use the section headings below as an on-page starting point. Keep only source-grounded facts and write every clinical Assessment, Plan or Progress judgment yourself.
Copy these headings into your documentation workspace
S — Subjective
________________________________________
O — Objective
________________________________________
A — Assessment
________________________________________
P — Plan
________________________________________
Keep what the client reported distinct from what the therapist directly observed whenever the format calls for that distinction.
An AI draft is not the therapist’s Assessment, Plan or Progress judgment. Add only the interpretation and next steps you independently stand behind.
Check names, timing, quotations, interventions and agreed plans against the eligible session source before separately saving the record.
Choose SOAP when the distinction between the client's report and the therapist's direct observations needs to remain visible. DAP combines both under Data, so it is shorter but does not preserve that split.
Editorial page by Intuita, updated 25 July 2026. Examples are fictional and templates are educational starting points, not mandatory clinical standards.
When you request it, Intuita prepares a SOAP draft from the eligible session source. You review and edit the draft, write the clinical Assessment and Plan you stand behind, and separately choose whether to save it to the record.
Requested AI draft — you review and edit before a separate save-to-record action
Do not use an AI draft to invent or decide diagnosis, safety or risk status, referrals, homework, treatment changes, Assessment, Plan or Progress. A draft may organize only what the eligible source actually records. The therapist checks that source, supplies the clinical judgment, and decides what enters the record.
External references explain documentation conventions. Local law, professional standards and practice policy take priority.
No — there's no legally mandated format. SOAP is a widely used convention, not a requirement. Many practices and EHRs support it as a default option.
DAP is more compact — Data, Assessment, Plan — and drops the split between subjective and objective. SOAP deliberately separates the two.
Yes. You select SOAP and request a draft, then review and edit it before a separate save-to-record action. Intuita supports nine formats in total.
Yes — the four sections are a starting point. You always review and adjust the draft note yourself before it goes into your file.
Apply to test Intuita in your own therapist workflow for one month. No payment is required during the pilot. Intuita is currently accepting therapists and practices for a one-month free pilot.
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