SOAP Note: Documentation best practices guidelines for therapists at Rula

Clear and precise documentation is vital for effective mental health care, especially in telehealth environments. It promotes continued access to care, supports ethical and legal obligations, enhances communication among providers, and drives improved patient outcomes. Progress notes should strike a balance between capturing essential details about client progress and safeguarding client confidentiality.

Rula’s templates are designed to help streamline the documentation process, ensuring all required elements are clearly addressed. This article highlights best practices for writing high-quality SOAP notes that align with industry and insurance standards. Examples in each section demonstrate sample documentation for a patient receiving treatment for Major Depressive Disorder.

Examples with Rationale and Best Practice Recommendations

Measurement-Informed Care (MIC)

What to Document:  

  • Select “Yes” to indicate that you reviewed the most recent MIC data. 
  • Make a selection(s) under “Based on the clinical measures” to indicate how you used the MIC data to inform treatment. 
  • For any case involving imminent danger to self/others, a C-SSRS score 2> , and/or PHQ-9 score above 19, a safety plan is required to be present in the chart and the client should be offered crisis resources, like the Rula crisis hotline.

Rationale: Clinical tools like MIC provide objective data to track symptoms over time, ensuring treatment effectiveness and improving clinical decision-making. They also support value-based care models. To learn more about MIC, its effectiveness, and how to utilize it with clients, please visit this article

Example

 

Subjective

Current Symptoms:

What to Document: This section captures the client's self-reported experiences, symptoms, and concerns. It may include their mood, thoughts, perceptions, or observations about their mental health currently experienced or experienced since last session. Direct quotes from the client are encouraged.

Rationale: The subjective section provides insight into the client’s lived experience and symptoms, how they understand their symptoms, and how the client believes their symptoms are impacting their functioning. This can assist with demonstrating medical necessity.

Example:

“The client reported persistent feelings of sadness and hopelessness, stating, "I feel like I’m stuck in a dark hole, and nothing I do matters anymore." She described difficulty concentrating at work and feeling fatigued despite sleeping 9–10 hours a night. The client also expressed feelings of guilt about being "a burden" to her family and reported losing interest in hobbies she previously enjoyed, such as painting. She denied current suicidal ideation but admitted to having fleeting thoughts of "not wanting to exist" last week.”

O - Objective

What to document: Observable, measurable data gathered by the therapist during the session, such as the client’s demeanor, appearance, or behaviors. This should be documented using non-judgemental language.

Rationale: Complements subjective input with factual, observable information for a balanced view.

Example:

  • “Client appeared with a flat affect and limited eye contact throughout the session.

  • Speech was soft and slow, with frequent pauses.

  • She sat slouched in her chair and exhibited minimal physical movement during the session.

  • Client presented as disinterested in completing a behavioral chain analysis today in session, stating that she “had no spoons to do this today”.

  • No observable signs of psychomotor agitation or retardation beyond posture and slowed speech.”

A - Assessment

What to document: Clinician’s professional interpretation of the subjective and objective data. May include progress, challenges, or diagnostic impressions regarding how each symptom is resulting in difficulty in client functioning in key domains of life (e.g. social, occupation) or a negative quality of life for the client. This should also address risk/danger to the client or others. 

Rationale: This synthesizes information from the prior two sections to establish a clear clinical conceptualization of the client, their needs, and how ongoing therapy supports their pursuit of their treatment goals, ultimately setting the stage for a strong case for medical necessity of care. Documentation of functional impairment is vital to prove a case of the medical necessity of care. If one is finding there is little or no impairment, this can be a sign to consider termination, especially because insurance will not cover ongoing sessions without medical necessity.

Example:
“The client presents with symptoms consistent with major depressive disorder, including persistent low mood, anhedonia, fatigue, excessive guilt, and concentration difficulties. The high PHQ-9 score aligns with her subjective and observed experiences, further supporting the diagnosis. While the client denies active suicidal ideation, her fleeting passive thoughts of "not wanting to exist" warrant ongoing monitoring. The depressive symptoms appear to significantly impair her occupational and social functioning. Should symptoms continue at this intensity for two more weeks without improvement, outpatient therapy may not be the appropriate level of care. ”

P - Plan

What it includes: Clear next steps for treatment, including acknowledgement of the evidence-based modality used, interventions, homework, current treatment goals, and potential future goals. 

Rationale: Provides a roadmap for continued care and ensures accountability. Additionally, insurance partners expect to see clear documentation of what the client will do to make progress toward treatment goals between sessions. 

Example:

  • Initiate weekly CBT sessions to address cognitive distortions and introduce behavioral activation (e.g., painting for 15 minutes daily) to improve mood.

  • Assign a mood journal and daily gratitude list as homework.

  • Reassess symptoms in 2 weeks using client self-report and GAD/PHQ; Should symptoms continue at this intensity for two more weeks without improvement, therapist will refer client to an IOP and medication evaluation

  • Recommend consultation with a primary care physician to rule out medical contributors to fatigue.

Diagnosis

Diagnosis: 

What to Document: Clinically appropriate diagnosis/diagnoses

Rationale: A diagnosis helps determine the best treatment options for the client and informs the insurance partner of the specific condition being treated with therapy.  At least one F-code is required to bill for services.

Best practices: 

  • Within each progress note, refer to DSM-5 for diagnostic criteria, and speak to the diagnostic criteria throughout your documentation (E.g. Symptoms, Functional Impairment, Session Summary, and Plan to address diagnosis).
  • Support the assigned diagnosis throughout the note with evidence of observed behaviors, assessment tool data, and reported symptoms.
  • Including an improvement in specific symptoms that the client previously experienced is another way to support a billing diagnosis. For example, for a client with bipolar disorder, you may include that the client denied experiencing recent manic symptoms. 
  • Periodically review diagnoses for their ongoing accuracy and relevance to the client’s current situation. If a diagnosis is no longer applicable due to progress or changes in symptoms, document the rationale for its removal and communicate this with the client.
  • For other best practices regarding diagnoses, please check out this article. 

Example: “F33.2: Major depressive disorder, Recurrent, severe without psychotic features”

 

Length of Treatment, Session Frequency & Session start/end time:

What to document: You can only bill for time actively spent with the client, not time spent waiting for the client or documenting the session. You may only bill for the entirety of the clinical hour if 53+ minutes were spent with them. In other words, only the time spent with the client influences the CPT code billed.

Rationale: Documentation of time spent with the client and the associated CPT code needs to be accurate. Sessions that start and end on the :00 or :30, especially regularly, are often flagged for auditing.

 

Treatment Plan

What to document: Record the client’s goal in their own words (“Client’s Goal”), translate that goal into clinical language (“Clinical Goal”), and measurable actions the client will take to work toward their goal (“Short-Term Objective(s)”).

Best practices:

  • Utilize the SMART (Specific, Measurable, Achievable, Realistic, Time-Bound) framework to develop treatment goals. The Short-Term Objective section of the Rula Treatment Plan is where you should specify the measurable steps, behavior shifts, and/or skills that the client needs to make progress toward their goal
  • Ensure treatment goals are related to the DSM-5 criteria for the client’s assigned diagnosis(es).
  • Consider up to 3 treatment goals. More than 3 can feel overwhelming to a client and potentially dilute the efficacy of treatment.
  • In order to meet compliance standards, update the treatment plan at least every 3 months.

Example: 

  • The client reports their goal is to: “Improve my mood and enjoy my life again”
  • The client’s clinical goal is: Skill acquisition; Symptom reduction
  • Short-Term Objective: “Learn three new CBT skills and practice each at least twice a week, in order to improve mood."
  • Why the example goal is SMART:
    • Specific: The goal clearly defines the actions (learning and practicing CBT skills) and the desired outcome (improve mood).
    • Measurable: Progress is measured by the number of skills learned and the frequency with which they are practiced.
    • Achievable: This activity (learning/practicing CBT skills) are realistic and manageable for most clients.
    • Relevant: The goal directly addresses the client’s depression, aligning with their diagnosis and desire for symptom improvement.
    • Time-bound: The eight-week timeframe provides a clear deadline for achieving the goal.

A final “rule of thumb” to keep in mind when documenting SOAP Notes is to consider how the patient would react to reading your clinical notes. After all, clients can and do request their record often, and we want to ensure that they feel honored and respected by their care providers when they read how you wrote about them! 

Want to see how all of this fits together to create an effective, compliant note? Rula offers a robust Sample Documentation Library, including examples of many different SOAP notes for adult, child, couples, and families!

 

 

Was this article helpful?

0 out of 0 found this helpful