Why SOAP notes take so long
A SOAP note has four parts: Subjective, Objective, Assessment and Plan. Writing one should take a few minutes. In practice many therapists spend far longer, and the delay rarely comes from the typing. It comes from three habits: waiting until the end of the day, trying to recall the session from memory, and deciding what a section should contain while writing it.
Each of these can be fixed without changing how you work with clients. The rest of this article goes through what belongs in each section, a worked example, and a handful of changes that reduce the time per note. If you are still choosing between SOAP, DAP and BIRP, the article on note formats compares them.
What goes in each section
The sections work best when each answers one question and nothing more.
- Subjective: what the client told you, in their words where it matters. Presenting concerns, mood as they describe it, events since the last session, and any change in sleep, appetite or relationships they report.
- Objective: what you observed and what was measured. Affect, appearance, speech, engagement, scores on a measure you administered, and risk screening you carried out. Keep interpretation out of this section.
- Assessment: your clinical judgment. How the session relates to the treatment goals, what themes or patterns you see, progress or lack of it, and current risk level with your reasoning.
- Plan: what happens next. Interventions you will continue or change, homework, referrals, the date of the next session, and anything you need to follow up.
The most common source of slow notes is blurring these lines. If a sentence could sit in two sections, you will spend time deciding where it goes. Decide once, write the rule on your template, and stop deliberating.
A worked example
The following is an invented, illustrative note for a fictional client. It is not drawn from a real person and it is not a model for every case. It shows a reasonable length and level of detail for an individual session of cognitive behavioural therapy.
| Section | Example |
|---|---|
| Subjective | Client reports a difficult week at work after a performance review. States she "froze" in the meeting and has since avoided checking email. Sleep is disrupted, about five hours a night, with early waking. Reports two panic-like episodes, each under ten minutes. Denies thoughts of self-harm. |
| Objective | Presented on time, casually dressed, speech normal in rate. Affect anxious and congruent with content, brighter when discussing her sister. Completed the GAD-7 in session: score 14, up from 11 at intake. Engaged throughout. |
| Assessment | Anxiety symptoms have increased over the past two weeks in response to a specific work stressor, with avoidance maintaining the distress. Client was able to identify the thought "I am about to be fired" and rate belief at 70 percent. No indication of acute risk today. |
| Plan | Continue weekly CBT. Began a thought record for the email-avoidance pattern and agreed to open her inbox for ten minutes a day. Review sleep routine next session. Next appointment in one week. |
That note is about 120 words. Notes in this range are usually quick to write when the structure is already settled, and they hold the facts a colleague or auditor would need. Your college or employer may expect more detail in some situations, so treat it as a starting point.
Habits that cut the time per note
These changes are small, and most do not depend on any software.
- Write the note within an hour of the session. Recall is better and the note is shorter because you are not compensating for forgetting.
- Schedule a five-minute block after each session. Leave a gap in the calendar rather than hoping to find one. Back-to-back clients are the main reason notes pile up at the end of the day.
- Jot three anchors in the room. One line each for the client's main concern, one observation, and the plan. These prompt the full note later and take under a minute.
- Use a template, not a blank page. Put the four headings and one or two cue questions under each. Starting from structure is faster than starting from nothing.
- Write in plain statements. "Client reports poor sleep" is enough. Avoid narrative that repeats prior notes.
- Carry forward only what changes. Copying a previous note and editing it is quick but invites errors and stale details. Prefer a short template and fill in what is new.
- Batch the signing, not the writing. Drafts can wait for a review pass, but the content should be captured the same day.
Common mistakes that cost time later
Speed is only useful if the record still does its job. Four problems show up repeatedly when therapists shorten notes.
- Notes so thin that the Assessment cannot be reconstructed. If you would be unable to explain a clinical decision from the note a year later, add a sentence.
- Copy-forward text that contradicts what happened in the session.
- Verbatim transcription of the session. A SOAP note is a clinical summary, not a transcript, and long notes cost reading time for everyone who uses them.
- Leaving risk assessment out of the note because nothing happened. A brief statement that you screened and what you found is worth the few words.
Your professional college sets the standard for what a record must contain. Check its documentation guidance rather than relying on a general article, including this one.
Where transcription and drafting fit in
Some therapists use a transcript as the raw material for the note. The idea is to talk, have the session turned into text, and then edit a draft instead of writing from scratch. It can shorten the work, but it adds a review step you cannot skip, because a draft can leave out a detail or state something the client did not say.
Astralcyte Notes is built around that workflow, with the processing kept on your computer. It transcribes the session on the device, deletes the temporary audio once the transcript is saved, keeps what it stores in an encrypted local vault, and drafts a note from a prompt you write yourself. If your prompt says "SOAP, four short sections, no interpretation under Objective", the draft follows that structure, and you edit it before it goes into the record. There is also a dictation mode for speaking a note after the session without recording the conversation. Whether a tool like this is appropriate for your practice depends on your regulator and your clients' consent. The practice page explains how to check for your profession and location. For a Canadian view of the privacy questions, see our Ontario checklist for AI note tools and the broader guide to AI note takers for Canadian therapists.
The tool does not integrate with an electronic health record, so you paste the approved note into your own system. If you are comparing it with cloud services, this comparison sets out the trade-offs.
A prompt you can adapt
Whether you draft by hand or with software, being explicit about structure saves editing. A prompt such as the following gives a consistent result:
- Write a SOAP progress note of no more than 150 words.
- Subjective: the client's report only, in plain language.
- Objective: observations and measures only, with no interpretation.
- Assessment: relation to treatment goals and current risk, if discussed.
- Plan: interventions, homework and next session.
- If something was not discussed, leave it out rather than guessing.
The last line matters. A good prompt tells the drafter to omit rather than fill gaps, and your review checks that nothing was added.
A short routine to start with
If you want one change to try this week, use this:
- Block five minutes after every session.
- Jot three anchor lines during or right after the session.
- Write the note from a four-heading template before the next client arrives.
- Review and sign at the end of the day.
Track how long a note takes for a week before and after. The number is usually lower than expected, and you will see which section still slows you down.