SOAP Notes for Therapists: A Complete UK Guide

SOAP notes are widely used in UK therapy private practice. If you see clients as a counsellor, psychotherapist or psychologist, there's a good chance you write SOAP notes, or are considering switching to them.

This guide covers what goes in each section, real worked examples, how SOAP fits with UK GDPR and BACP requirements, and how to write them faster without sacrificing quality.

What are SOAP notes?

SOAP stands for:

• Subjective — what the client reports: their presenting concerns, how they've been since the last session, what they want to work on today
• Objective — what you observe: the client's presentation, affect, behaviour, mental state
• Assessment — your clinical interpretation: how this session relates to treatment goals, progress or setbacks, clinical formulation updates
• Plan — what happens next: homework, goals for the next session, referrals, risk management actions

The format was originally developed in medicine and has been widely adopted across mental health and therapy professions because it provides a consistent, auditable structure for clinical documentation.

What to write in each section

Subjective

The Subjective section captures the client's experience in their own words or as closely as possible. This is not a verbatim transcript — it's a clinical summary of what the client brought to the session.

Include:

• Presenting concerns or themes for this session
• How the client has been since the last session
• Any significant events or changes in their life
• Their mood or emotional state as they reported it
• Their engagement with any homework or between-session tasks

Don't include: verbatim quotes (unless clinically significant), your interpretations, or observations — those belong in Objective and Assessment.

Objective

The Objective section captures what you observed as the clinician. This should be factual and behavioural — things another clinician could verify if they were in the room.

Include:

• Appearance and presentation
• Affect (emotional expression) — congruent, flat, labile, restricted
• Mood as observed (distinct from self-reported mood in Subjective)
• Thought process — coherent, tangential, pressured
• Behaviour in session — engaged, avoidant, tearful, agitated
• Any observable signs of risk

Assessment

The Assessment section is where your clinical judgement lives. This is your interpretation of what happened in the session and what it means clinically.

Include:

• How this session relates to treatment goals
• Progress or setbacks since the last session
• Your clinical formulation or any updates to it
• Patterns you noticed — themes, defences, relational dynamics
• Risk assessment if relevant

This is the most clinically rich section and often the most valuable if notes are ever reviewed.

Plan

The Plan section documents what happens next. Keep it concrete and actionable.

Include:

• Date and time of the next session
• Any homework or between-session tasks
• Goals or focus areas for the next session
• Any referrals made or planned
• Risk management actions if applicable

A worked SOAP note example

Here is a realistic example for a 50-minute CBT session:

SOAP notes and GDPR compliance in the UK

Clinical notes — including SOAP notes — are special category personal data under UK GDPR. This means they need a higher standard of protection: a lawful basis (usually contract, Article 6(1)(b)) plus a condition for health data (usually health care, Article 9(2)(h)).

For UK therapists, the key requirements are:

• Use reference codes, not names — identifying clients by a reference code (CLT-014) rather than their full name reduces risk significantly
• Store notes securely — clinical notes must not be stored in generic services like standard Google Drive without additional configuration. Purpose-built clinical record systems are the appropriate solution
• Have a Data Processing Agreement — if you use any software to store or process client notes, you need a DPA with that provider under UK GDPR Article 28
• Inform clients in your Privacy Notice — your privacy notice must explain that you keep clinical records and how they are stored
• Retention policy: there is no statutory retention period. BACP says private practitioners may keep notes for a minimum of three years after therapy ends, and many keep adult records for six or seven years. Document a period you can justify, and be able to delete records when it ends

BACP requirements for therapy notes

BACP's Ethical Framework expects members to keep adequate, accurate records of their work. BACP doesn't mandate SOAP or any other format, but SOAP suits this well because it is structured, factual and clinically auditable.

BACP also expects records to be kept confidentially and stored securely. Its Good Practice in Action resources cover record keeping in more detail.

How to write SOAP notes faster

For most therapists, the biggest challenge with SOAP notes is not knowing what to write — it's finding the time to write them well after a full day of sessions. A few approaches help:

1. Write immediately after the session

It's good practice to write notes as soon as possible after a session, while the clinical content is fresh. Leaving notes until the end of the day — or worse, the end of the week — increases inaccuracy and creates professional risk.

2. Use a template

A simple SOAP template with the four headings and a few prompts removes the cognitive effort of remembering what to include. Many therapists find that having the structure in front of them cuts writing time significantly.

3. Use AI post-session dictation

The fastest approach for writing SOAP notes is to speak a brief summary immediately after the client leaves and let AI format it into a complete structured note. You then review and edit the draft before saving it.

The simplest version of this for GDPR is a tool that works after the session, not during it, so the session is not recorded. You speak your clinical summary after the client has left and the AI structures it into SOAP format.

NoteSono uses this approach. It stores notes in the EU, is ICO registered (ZC045529), and is designed for UK therapists in private practice. Some AI processing uses providers outside the UK and EU under data processing terms that exclude training on your data. SOAP is included on the free plan.

Alternatives to SOAP notes

SOAP is the default for many UK therapists, but it's not the only option:

• DAP notes — Data, Assessment, Plan. Faster to write, slightly less structured. Good for experienced clinicians
• BIRP notes — Behaviour, Intervention, Response, Plan. Better suited to goal-focused therapies like CBT
• Narrative notes — free-form clinical narrative. More flexible but harder to audit
• GIRP notes — Goals, Interventions, Response, Plan. Similar to BIRP, common in US-influenced settings

Common SOAP note mistakes to avoid

• Writing opinions as facts — "Client was aggressive" vs "Client raised their voice and left the session early"
• Including third-party information without care — details a client shares about family members are third-party data and should be handled carefully
• Using jargon without definition — if notes are ever reviewed, they should be understandable to a reasonable professional
• Leaving risk undocumented — if you assessed for risk, document that you did and what you found, even if the outcome is "no current risk"
• Inconsistent client identifiers — use the same reference code consistently across all notes for a client

Try NoteSono free

NoteSono drafts SOAP notes from a short post-session voice summary. No session recording. Free plan, no card needed. ICO registered and designed for UK therapists.

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