How to Write Marriage & Family Therapy Soap Notes

Documentation might be the most important thing you do as a therapist. SOAP notes provide you with simple but thorough documentation about your clients' progress in therapy. SOAP is an acronym for subjective, objective, assessment and plan. Each of these concepts is essential to helping your clients reach therapeutic goals.



A SOAP note keeps you and your clients on track with their treatment plan, measures the amount, if any, of progress and outlines the objectives you need to meet.

Instructions

• 1

  Describe your initial impression of your clients, as well as your clients' viewpoints, in the "subjective" area. You should do this at the beginning of each session and only record impressions relating to your clients' therapeutic treatment.

  For example, a subjective assessment could state, "Bob and Jane appeared to be distant from each other at the start of the session but grew more responsive to one another when discussing the incidents of the prior week," or "Jane reported Bob was more attentive than usual during the prior week."

• 2

  Record all therapeutic techniques used as well as measurable and observable progress in the "objective" area. The objective area should be strictly factual -- what you see and hear from your clients.

  Examples of objective statements would be: "During talk therapy, Jane stated she and Bob had a wonderful dinner and enjoyed one another's company. Therapist observed Jane smiling during this statement as she placed her hand on Bob's knee."

  Record therapeutic progress data as a ratio or percentage, if possible. Otherwise, simply report the progress from the prior session.

• 3

  Assess the therapeutic data you observed and heard during the session in the "assessment" area. Your assessment will include data recorded in both the subjective and objective areas.

  For example, an assessment of a marriage counseling session could state, "Bob and Jane have completed a therapeutic goal to spend uninterrupted time together one night a week. Both clients reported this was enjoyable and they felt more connected to each other. Therapist observed the clients touching each other and smiling 10 percent more than prior session."

• 4

  Establish a plan for next session in the "plan" area. Set a date and time for the next therapy session. Provide your clients with a workable goal for the next meeting. For example, "Jane and Bob will go on a date with another couple during the next week. They will compliment one another in the presence of the couple at least three times."

• 5

  Sign the SOAP note with your name, credentials and date of the session.