SOAP note examples
SOAP notes for EMDR sessions
EMDR gives you something most modalities don't: built-in numbers. SUD and VOC ratings taken at protocol-defined moments turn "client is processing the trauma" into a measurable trajectory, and naming the phase you worked in (Phase 4 desensitization, Phase 5 installation) tells a reviewer exactly where the client sits in the standard protocol. The other EMDR-specific skill is restraint: the note should identify the target memory by label and ratings, never by graphic narrative. What surfaced during sets belongs in the record only as themes and channels — the details stay in session.
Fictional example: a 41-year-old client, fifth EMDR session, reprocessing a target memory labeled "the highway accident" with a pre-session SUD of 7. All details are invented for illustration.
Example note
Subjective
Client reported intrusive images of the target memory decreased from daily to "two or three times this week." Described driving past the accident location without detouring for the first time: "I noticed my hands on the wheel, but I kept going." Reported using the calm-place exercise twice between sessions with good effect. Sleep stable at 7 hours; one nightmare early in the week, less vivid than previous. Denied avoidance of car travel this week. No medication changes.
Objective
Client oriented and grounded at session start. Phase 4 desensitization on established target ("the highway accident"): SUD opened at 6, closed at 3 after eleven sets of bilateral eye movements. Brief abreaction during set six (tearfulness, rapid breathing); client returned to window of tolerance within two sets using grounding and resumed processing. VOC on preferred cognition "I survived and I'm safe now": 4/7 at close. Client alert and stable at session end; closure exercise completed.
Assessment
Desensitization is progressing along expected lines: SUD has moved from 7 at target setup to 3 today, with associative channels shifting from sensory fragments toward present-oriented material — a typical marker of adaptive resolution. The abreaction was contained within the session and client demonstrated capacity to self-regulate and resume processing, supporting continued Phase 4 work without additional resourcing. In-vivo driving behavior corroborates generalization outside session. Target not yet at SUD 0; installation deferred. Risk: no suicidal or homicidal ideation reported or observed; client left session grounded.
Plan
Continue weekly EMDR. Next session: resume Phase 4 on the same target, reassess SUD at start; if SUD reaches 0–1, proceed to Phase 5 installation of "I survived and I'm safe now" and Phase 6 body scan. Between sessions: client to use calm-place exercise as needed and log intrusions briefly (frequency only, no detail). Reviewed contact procedure if distress spikes between sessions. Next appointment scheduled.
Tips for EMDR notes
- Record SUD and VOC at the protocol-defined points — start and end of desensitization, installation — so the numbers form a trajectory across sessions, not a one-off.
- Name the phase explicitly ('Phase 4 desensitization,' 'Phase 5 installation'): it locates the session in the eight-phase protocol and shows the work is structured, not open-ended.
- Identify the target by its working label and ratings, not its content — 'established target, SUD 6 to 3' documents treatment; the narrative of the memory does not need to be in the record.
- When an abreaction occurs, document three things: that it happened, what you did (grounding, returning to bilateral stimulation), and that the client was stable at session end.
Pitfalls to avoid
- Transcribing what came up during sets — channel content written verbatim turns the note into trauma narrative; summarize as themes ('sensory fragments shifting to present-oriented material').
- Omitting closure documentation on incomplete targets — if the SUD isn't at 0, the note should show you closed the session deliberately and the client left grounded.
- Reporting SUD without context: 'SUD 3' means nothing alone; 'SUD opened at 6, closed at 3, down from 7 at setup' is data.
- Skipping the risk line after an emotionally intense session — high-activation sessions are exactly when a reviewer expects to see risk explicitly assessed.
Notes like this, drafted on your Mac.
CouchNotes turns your session — recorded, dictated, or imported — into a structured draft in this format, entirely on your device. Free SOAP/DAP/BIRP templates meanwhile.