Progress Note (SOAP/DAP) Template: Write Clear Session Notes in SOAP or DAP Format

About this tool

Progress notes are the running clinical record of treatment. A good note documents what occurred in a session, your clinical thinking about it, and what comes next, in a way that another provider could pick up if needed. Notes also support continuity of care, demonstrate medical necessity for payers, and protect both client and clinician if records are ever reviewed. Strong, timely documentation is one of the most practical risk-management habits a clinician can build.

SOAP is the most widely used structure: Subjective (what the client reports), Objective (what you observe, including mental status and behaviors), Assessment (your clinical interpretation and progress toward goals), and Plan (next steps, homework, and the next appointment). DAP collapses subjective and objective into a single Data section, followed by Assessment and Plan, which many therapists prefer for its brevity. Both formats serve the same purpose; choose the one your setting uses.

Write notes in clear, objective, behavioral language. Record observable facts and quote the client where it is clinically relevant, rather than speculation or judgment. Link each note to the active treatment plan so progress toward objectives is visible across sessions. Distinguish the progress note, which becomes part of the medical record, from psychotherapy process notes, which under HIPAA can be kept separately and receive added protection when stored apart from the record.

Keep it concise but complete. A note should stand on its own months later and answer the basic questions: what was the client's status, what did you do, how are they progressing, and what is the plan. Document promptly while the session is fresh, and store completed notes only in a HIPAA-compliant system.

A few habits cause most documentation problems: copying language from a previous note without checking it still fits, writing assessments so vague they could apply to any client, and leaving out a risk statement even when the session included no safety concerns. A short, explicit line such as no SI/HI reported or observed is worth more in a review than a paragraph of general impressions. If your caseload includes couples, families, or groups, note who was present and adapt the subjective or data section so it reflects each person's report where relevant.

Insurance reviewers and licensing boards look for the same things: does the note tie back to the active treatment plan's goals, does the intervention match the billed service code, and is the plan specific enough to show ongoing medical necessity. A template like this one keeps that structure consistent across a caseload, which makes both audits and your own review of a client's progress faster.

Telehealth sessions bring a few extra documentation habits worth building in: note the client's location at the time of the session, confirm and document telehealth informed consent where your state or payer requires it, and record any technical disruption that affected the session, such as a dropped call that shortened the time. Some payers also expect a modifier or place-of-service code alongside the CPT code for a telehealth visit, so check current billing guidance for your setting before submitting.

Reviewed by Michael Callans, MSW
Reviewed the SOAP and DAP structures for fidelity to standard clinical documentation.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text revision (DSM-5-TR). American Psychiatric Association Publishing; 2022.
2. American Psychological Association. Record Keeping Guidelines. Am Psychol. 2007;62(9):993-1004.

Progress Note (SOAP/DAP) Template FAQ