I am a clinical psychologist with 18 years of experience in private and group practice. Over the years I have learned what insurance usually wants to see in a note. I used to write extensively, which was very time-consuming. Over time I refined my approach to be more information-driven — cutting the details that weren’t necessary — and better protected against clawbacks or audits from insurance companies.

When you search for “SOAP notes” online, most guides only offer a minimal description of what goes in each section. That’s because SOAP notes were designed for the medical field, not for psychology. Below is an example of a note I’ve written (with composite, fabricated client information for protection) that meets criteria for insurance purposes. Under each section I’ve added, in italics, what we’re actually trying to capture.

The client details in the example below are fabricated and do not represent a real person. They’re included only to illustrate format and phrasing.

Why generic SOAP templates fall short for therapists

A medical SOAP note and a psychotherapy note are not the same animal. The standard template tells you what the four sections are, but not how to write them so a payer can see medical necessity, functional impairment, and a coherent treatment arc. If SOAP isn’t the right fit for your workflow, the DAP note format is a leaner alternative worth knowing — but for insurance-facing documentation, a well-built SOAP note is hard to beat.

A SOAP note that meets insurance criteria

Subjective

Client’s reported experience and mood. It’s good practice to include direct client quotes where possible.

Client expressed feelings of empowerment after enforcing boundaries with her sister during an argument, indicating “I told her I would not be talked to that way, and walked away.” She also shared concerns about her family’s drinking and her own recent experience of drinking too much at a family outing, indicating a need for better self-control and boundaries with her family. She discussed a recent date that made her feel respected and highlighted her desire to date intentionally, reflecting on past dating behaviors and acknowledging a tendency to come on too strong. Overall, client reported feeling anxious but less depressed due to better interactions with the people in her life.

Objective

Interventions used, the clinician’s observations, how the client responded during session, and any mental status observations.

During the session, the therapist utilized Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) techniques. Interventions included reflective listening to validate the client’s feelings, encouraging self-reflection on her values, and identifying core values such as being hardworking and independent. The therapist emphasized the importance of self-care and mindfulness, prompting the client to develop two simple action steps related to her values, and encouraged journaling to process her thoughts and feelings. Client was engaged during session and participated actively. Progress was noted as the client demonstrated insight into her dating behaviors and family dynamics, expressing a commitment to prioritize her own needs and establish boundaries.

Assessment

Clinical interpretation, symptoms, functional impairment, and a statement of medical necessity.

Client is experiencing emotional distress related to her family dynamics, particularly her family’s drinking and her older sister’s overinvolvement in her life. She exhibits symptoms of guilt and frustration that impact her social relationships and self-esteem. Her symptoms are consistent with generalized anxiety disorder, including excessive worry about family members’ approval and reactions and difficulty controlling anxious thoughts even when she recognizes the fears may be exaggerated. Client also reflects on impulsivity in dating, recognizing patterns that contribute to feelings of embarrassment and confusion. These symptoms contribute to functional impairments in her social interactions and self-care practices. There is no indication of suicidal or homicidal risk; client is focused on personal growth and self-improvement. Continued therapy is medically necessary to address these functional impairments and support the client’s progress in establishing healthier boundaries and self-care practices.

Tying the assessment to a specific diagnosis is what makes medical necessity legible to a payer — pairing the symptom picture with the right ICD-10 code and the CPT code for the session you actually delivered is what keeps a note audit-ready.

Plan

Next steps, including homework, items pulled from the treatment plan, and when the next session is scheduled.

Client will develop two simple action steps related to her values of being hardworking and independent, to be discussed in the next session. She is encouraged to continue journaling about her thoughts and feelings regarding her family dynamics and dating experiences. The therapist will review the CBT handout with the client in the next session, scheduled for Thursday. Client will also practice deep breathing at least once a day.

Helpful phrases by section

For the Subjective section:

Client expressed feelings of __________
Client reports experiencing __________
Client reported ongoing difficulties managing __________
Client reported ongoing challenges related to __________
Client reported progress in __________

For the Objective section:

During the session, the therapist utilized __________ (modalities)
Interventions included __________
Therapist emphasized __________
Client was engaged during session and participated actively
Client showed defensiveness during/about __________

For the Assessment section:

She exhibits symptoms of __________
Client’s symptoms are consistent with __________
These symptoms contribute to functional impairments in __________
Client shows moderate functional impairment in occupational and social domains due to __________
Continued therapy is medically necessary to address __________

For the Plan section:

She/he is encouraged to continue __________
Client will develop __________
Client will practice __________ daily / 3 times a week
Therapist assigned homework including __________
Continue weekly individual therapy focusing on __________
Next appointment scheduled for __________

Other useful clinical phrasing

Aided client in developing insight about __________
Assessed risk of __________
Built rapport with client by __________
Helped client challenge automatic negative thoughts
Clarified __________
Helped client with problem-solving about __________
Examined pros and cons about __________
Worked on identifying triggers for __________
Normalized client’s feelings of __________
Helped client process thoughts and feelings
Encouraged client to __________
Worked on coping skills
Supported client with __________
Introduced mindfulness exercises
Assessed / evaluated __________

Make the note the easy part

The notes that survive audits aren’t the longest — they’re the ones that connect the client’s presentation, the intervention, and medical necessity in a few clean sentences. That gets faster when your documentation tool is built for the workflow rather than fighting it. Mente360’s clinical notes are designed to keep that structure in front of you so the SOAP note is the easy part of the session, not the part that eats your evening.

How to Write SOAP Notes That Hold Up to Insurance Audits