SOAP note examples
SOAP notes for telehealth sessions
A telehealth note is an in-person note plus a documentation layer the format itself creates. Every session should open with the same recorded facts: where the client physically is (which determines whether your license covers the session), that consent for telehealth is current, what platform was used, and that you verified you were speaking to a client who could speak freely. The Objective section changes too — you're observing through a camera, so note what you could and couldn't assess. None of this is busywork: location and consent lines are exactly what licensing boards and payers check first when a telehealth record is reviewed.
Fictional example: a 47-year-old client, twelfth session of weekly therapy for depression, conducted by video from the client's home office, with one connection drop mid-session. All details are invented for illustration.
Example note
Subjective
Client reported mood "flat but functional" this week, rating it 5/10. Described returning two phone calls she had avoided for a month: "I did them badly, but I did them." Behavioral activation log completed five of seven days; the two missed days followed a poor night's sleep. Reported continued adherence to antidepressant with no side-effect changes. Noted that sessions from home feel easier to attend but that she misses "the drive home to think."
Objective
Session conducted via secure video platform per current telehealth consent. Client confirmed physical location at start of session (home, in-state); clinician licensed in client's state. Client alone in a closed room; privacy confirmed verbally. On camera: groomed, adequate lighting, fatigued affect brightening when describing completed calls. Speech normal rate. Connection dropped at minute 31; session resumed by the agreed phone backup within three minutes, remainder completed by audio. PHQ-9 administered by screen share: 11, down from 14. No suicidal ideation reported; item 9 score of zero confirmed verbally.
Assessment
Depressive symptoms continue a gradual response to behavioral activation (PHQ-9 trend 17, 14, 11 across four weeks), with avoidance behavior — the maintenance target — now being approached imperfectly rather than deferred, which client could acknowledge as progress without prompting. Sleep remains the main disruptor of activation adherence. Telehealth delivery remains clinically appropriate: attendance is more consistent than the in-person period, engagement is sustained on video, and symptom severity does not indicate a need to step up care. Risk: none indicated; verbal screen negative.
Plan
Continue weekly video sessions; in-person available if clinically indicated. Next session: review full activation log and add one avoided-task exposure per week, starting with the insurance paperwork client identified (Goal 1, Objective 1b). Introduce brief sleep hygiene review next session given its link to missed activation days. Re-administer PHQ-9 in two weeks. Backup phone procedure reconfirmed. Next appointment scheduled.
Tips for telehealth notes
- Open every telehealth note the same way: client's physical location, your licensure for that state, consent on file, platform used, and privacy of the client's environment — a reusable block you fill in fresh each session.
- Verify location even with established clients — a client joining from a vacation rental across a state line can put the session outside your license, and the note should show you asked.
- Document what the camera let you assess and what it didn't: 'visible from shoulders up; psychomotor observation limited' is honest and protective.
- When the connection fails, record the timeline: when it dropped, how contact was re-established, how much session was completed, and whether the time billed matches.
Pitfalls to avoid
- Copying the location/consent block forward without re-verifying — boards treat 'client confirmed location' as a per-session fact, and identical timestamps across notes read as fabrication.
- Skipping the privacy check because the client is at home — a partner within earshot changes what a client will disclose, and the note should show you assessed it.
- Assessing risk over video exactly as you would in person without documenting the plan difference — note the client's location and local emergency contact in case escalation is needed remotely.
- Leaving a mid-session disconnection out of the note — an unexplained 35-minute session billed as 50 minutes is precisely the discrepancy payer audits are built to find.
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.