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Compliance and documentation

The “O” is the hardest part of SOAP notes. Here’s how one therapist tackles it

You can make writing the “objective” section of SOAP notes even easier.

January 17, 2025 • Updated on November 17, 2025

6 min read

Progress notes help you stay on track with your clients’ treatment plans and provide helpful information that insurance companies need in order to pay you. To make sure you incorporate all the right information in progress notes, you may use standardized templates. One of the most widely used is SOAP notes, which stands for “Subjective, Objective, Assessment, and Plan.”

While SOAP notes can make it easier to support your clients’ care and submit insurance claims, it’s not uncommon to hit a roadblock with this documentation format. The objective portion of SOAP notes in particular can be difficult for many therapists to write — but keeping a few important points in mind can help you stay on track.

What goes in the "objective" part of a SOAP note?

The objective portion of a SOAP note is the place to document what you observed during a session, ideally backed by specific examples or other forms of data. This section is not for making subjective conclusions about your client’s health or mental status, but rather for recording concrete facts about the session and how they showed up to it. 

For example, if your client arrived 15 minutes late and was wearing visibly dirty clothes, those observations would go into the objective session. If you performed any assessments that yield clear-cut results — like the GAD-7 or PHQ-8 — you could also include those results.

Why the “O” in SOAP notes can be so hard

SOAP notes were originally developed for medical settings, not necessarily for mental health clinicians. At a doctor’s office or hospital, the “O” (which stands for “objective”) typically includes information like vital signs and lab results. But this section of the note-taking process may not always translate perfectly to mental and behavioral health care.

“Therapists can get hung up on the objective part of the notes, because mental health isn’t always as cut and dry,” says Madison Hamm, LCSW, a psychotherapist with Grace Therapy & Wellness in Austin, Texas. 

Ideally, the objective observation portion of SOAP notes should be backed up by tangible evidence, rather than your own interpretation or opinion of a client’s progress. If you work in an inpatient setting, this might be easier (for example, it’s objective to say a client sat out of a treatment group).

But if you see clients in an outpatient setting, it can be tricky to come up with objective observations you can support with evidence — especially because you may be used to working with emotions, which can often be subjective.

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How to be objective in your SOAP notes

The objective observations in your SOAP notes should be based on your clinical assessment, reports from others, or other collateral information. The goal is to ensure you’re communicating accurately how the client is presenting rather than relying on your own opinion of a situation or individual. 

To be sure her objective notes are up to par, Hamm always uses “as evidenced by” or “due to.” 

“This ensures the clinical observations in the notes are credible and not just based on your opinion,” she says.

Everything in this section should be either unambiguous (i.e., the results of an assessment or the time a client arrived) or convey clearly observable information (i.e., if the client cried during the session). If you find yourself writing something that’s based solely on your opinion or clinical judgment, it’s probably something to save for the assessment section.

Examples of objective observations include:

  • Client has remained sober for 45 days based on report and drug screenings.
  • Client arrived five minutes late based on the agreed-upon time.
  • Client was guarded in session as evidenced by crossed arms and legs and avoiding eye contact.
  • Client has been struggling with thoughts of self-harm as reported in an email from their spouse or parent.

What to avoid when documenting objective observations

On the other hand, avoid subjective statements like “the client looked sad in session” or “the patient seemed tired today,” especially if you can’t back them up with evidence (such as “as evidenced by crying” or “as evidenced by slouching on the couch and reporting they only got three hours of sleep last night.”)

If you’re not sure whether something belongs in the objective section, gut check yourself. Could someone reasonably disagree with what you’ve written or perceive the situation differently? If you had to supply proof of what you’ve written, could you? The answers to questions like these should help you decide whether a comment really belongs in the objective portion of a SOAP note.

Proper documentation can be time-consuming, but taking steps to ensure your progress notes accurately reflect your client’s progress can help ensure your treatment plan is on the right track — and that insurance payers have all the information they need to pay you for the important services you provide.

Use Headway’s progress note templates

While there are many options for documentation, Headway's in-product templates are designed to make note-taking fast and efficient, all while helping to take out the guesswork. Plus, our templates are included at no additional cost for Headway providers. Headway’s team and tools are here to make everything about working with insurance companies (including compliance!) as easy as possible.

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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

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