Templates by document

SOAP note format and example for therapists

A SOAP note format for therapists, with an example line for subjective, objective and plan in every therapy.

Choose your therapy

Formats for

SOAP & session notes by therapy

Speech therapySpeech therapy SOAP note template and exampleA speech therapy SOAP note template with a trials-and-cues table and an example entry for Subjective, Objective and Plan.
Occupational therapyOccupational therapy SOAP note template and examplesAn occupational therapy SOAP note template with an OT data table, plus paediatric and adult examples for each section.
ABA & behaviour therapyABA session note template with examplesAn ABA session note template in SOAP format, with worked DTT and NET examples and a trials and prompts table.
Early intervention & child developmentEarly intervention session note template and SOAP exampleAn early intervention session note in SOAP format, with a parent coaching table and fictional example entries.
PhysiotherapyPhysiotherapy SOAP note template and exampleA physiotherapy SOAP note template with example entries for a back-pain outpatient and a neuro patient seen at home.
Multidisciplinary rehabilitationRehabilitation SOAP note template and exampleA rehabilitation SOAP note example and template for any discipline, with each session activity tied to a shared team goal.
Multidisciplinary rehabilitationRehab team meeting and case conference notes template with examplesAn MDT meeting minutes format for rehab teams, with sample entries and every action given one owner and a due date.

The essentials

What goes in each part of a SOAP note?

Subjective is what you are told, objective what you saw, assessment your judgement, plan what comes next.

Subjective: what the person, parent or carer tells you. Example: "Mother reports A. slept poorly and practised the naming game twice since last session."
Objective: what you saw and counted, with the support given. Example: "A. named 6 of 10 picture cards with a first-sound cue; 3 of 10 without a cue."
Assessment: your clinical judgement about the session against the goals. Write this yourself from the objective data; templates give guidance only.
Plan: what you will do next session, any change in approach, and home practice given.

Keep each part to what belongs there. Mixing observation and interpretation is the most common reason notes are hard to read later.

How do SOAP notes differ across therapies?

Speech logs targets and cues, OT logs assistance, ABA logs trials and prompts, physio logs exercises.

Speech notes centre on target data, cues and carryover. OT notes describe tasks and assistance, such as "buttoned 3 of 5 large buttons with hand-over-hand support on the first two". ABA session notes list programmes run, trial data and prompt levels, often reviewed by a supervisor.

Physiotherapy SOAP notes, called PT daily notes in the US, record pain, exercises with sets and repetitions, and the response to treatment. Early intervention and rehab notes record who attended and what happens before the next visit.

SOAP, DAP or narrative note: which format should you use?

Any of the three works if your clinic uses it consistently. SOAP suits measurable targets best.

SOAP: four parts, keeping what was reported apart from what was observed. Suits sessions with measurable targets.
DAP: data, assessment, plan. Shorter, and common in counselling and some ABA services.
Narrative: a short paragraph in time order. Quick to write but harder to scan for data later.

All three are acceptable if your clinic uses them consistently.

How long should a therapy SOAP note be?

Usually five to fifteen lines, written the same day, with numbers in place of "good".

Long enough that someone who was not in the room knows what you did, what happened and what comes next. Write it the same day while you remember the counts, and use numbers rather than words like "good" or "improving" wherever you have them.

Notes in a multilingual session

Record the languages used and who attended, and note who said what.

Record the languages used, especially when targets were practised in one language and the family uses another at home. Note who attended. A grandparent or older sibling sometimes brings the child, and their report may differ from the parent's. Record it as it is, with who said it.

About soap & session notes

A SOAP note records a single therapy session in four parts. Subjective is what the person or family reports. Objective is what you observed and measured. Assessment is your clinical reading of the session. Plan is what happens next. The templates below give speech, OT, ABA, early intervention, physiotherapy and rehab versions with example wording.

SOAP notes are the document you write most often. A good one takes a few minutes, lets a colleague cover your next session without phoning you, and holds the data your progress report will need.

ABA and early intervention services often call it a session note. The four-part logic still helps.

Questions

Can I see a SOAP note example?

Each therapy template page shows a fictional example entry for the subjective, objective and plan sections, using initials only. The assessment section has guidance only, because it is your clinical judgement.

What does SOAP stand for?

Subjective, objective, assessment and plan. The format came from medical record keeping and is now used widely in speech therapy, OT, physiotherapy and other therapies.

Is a session note the same as a SOAP note?

A session note is any record of a single session. A SOAP note is a session note organised into four parts. ABA and early intervention services often use their own headings.

Should I write the SOAP note during the session?

Record data during the session, on a data sheet or the session data tracker, and write the note straight afterwards. Writing full sentences mid-session takes attention away from the person.

Can I download a SOAP note as a PDF?

Yes. Fill the template in the report writer and download a PDF, or download it blank for paper notes.

Do SOAP notes go to the family?

They are usually part of the clinical record. Families more often receive a short session update or the periodic progress report, depending on clinic policy.

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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