Most SOAP notes pass a quick glance and fail a close read. The format tells you which four boxes to fill. It doesn’t tell you how much to put in them, and that gap is where therapy progress notes fall apart in an insurance audit.

Below is a typical SOAP note, the six things it leaves out, and the same session written in NoteNest from keyword selections in under 60 seconds.

What a SOAP note is

A SOAP note splits a session into four parts:

• Subjective: what the client reported, in their words or yours.
• Objective: what you observed, such as mental status, appearance, and behavior in session.
• Assessment: your clinical read on the client’s presentation and progress.
• Plan: what happens next.

It’s a solid framework. The problem is that it’s a minimum, and most clinicians treat it as the finish line.

A typical SOAP note example

Here’s a note for a virtual session with a client we’ll call Jerry, who is dealing with stress at work.

S: Client reports stress at work and trouble sleeping. States he has been having panic attacks.

O: Client appeared tearful and depressed. Cooperative.

A: Client continues to struggle with anxiety. Some progress noted.

P: Continue weekly therapy. Refer to psychiatry.

Every box is filled and nothing in it is wrong. But someone reading it later can’t tell what the therapist actually did, whether Jerry is getting better, or why this session was necessary.

What most clinicians leave out

These are the gaps that make therapy documentation hard to defend when a payer asks for records.

1. A full mental status exam. “Tearful and depressed” is two observations. Orientation, thought process, thought content, perception, memory, and insight go undocumented.
2. Evidence for what you observed. “Depressed” alone is a label. Depressed as shown by tearfulness, crying, and depressed posture is documentation.
3. Who was present and how the session happened. Individual or family, in person or virtual. Payers check this.
4. Specific interventions. This is the most common gap. Name the technique and what it targeted, not just “supportive therapy.”
5. Progress tied to treatment plan goals. “Some progress noted” doesn’t say which goal or how you know.
6. A plan with substance. “Continue weekly therapy” reads the same every week.

This is the detail reviewers look for when deciding whether a session supports medical necessity. It’s also what gets cut when you’re writing notes at the end of a long day. If you want the audit side in more depth, see how to pass a therapy insurance audit.

The same session written in NoteNest

Same client, same session. Here’s the note NoteNest generated, trimmed for length.

MSE

Jerry’s dress appeared to be within normal limits. His speech was within normal limits. His eye contact was within normal limits. His mood seemed depressed, evidenced by his being tearful, crying and depressed posture. His affect seemed congruent. He was cooperative. His thought process seemed logical. His thought content seemed appropriate.

Jerry’s perception seemed intact, as no hallucinations or delusions were reported or observed. His orientation x4 was intact. His short-term and long-term memory seemed intact.

Jerry’s insight seemed good, as he seemed to understand his issues and understand how to address them.

Session Content and Themes

Therapist engaged Jerry in an individual therapy session through a virtual setting. During the session, he explored some ongoing events and experiences with his coworkers and authority at work. He also discussed his feelings of stress, worry and nervousness, as well as panic attacks, difficulty sleeping and nightmares.

Interventions

Therapist used cognitive restructuring and assisted Jerry with correcting and reframing negative thoughts and irrational beliefs.

Therapist used a counseling style which was non-directive, empathetic, understanding, non-judgmental, validating and included use of humor.

Progress

Goal 1: Jerry will improve his rational thinking. Jerry seems to be making progress with this goal, evidenced by reports and observations of reduction in negative thoughts.

Goal 2: Jerry will improve his emotional expression. He seems to have neither improved or regressed with this goal, as there have been no observed or reported changes in mood.

Recommendations and Plan

Therapist recommends continuing counselling duration and frequency and working towards treatment goals. Further recommendations include making an appointment with a psychiatrist.

How the note got written

The therapist didn’t type any of it. Each sentence came from clicking keywords in five sections.

1. MSE. The All Normal toggle filled the full exam. Then under Mood, the therapist picked Depressed, then being tearful, crying, and depressed posture. NoteNest rewrote the mood line to include that evidence.
2. Session Content and Themes. Who was present is a required field. Under Events/Experiences/Interactions, the therapist picked explored, ongoing, events and experiences, with coworkers and authority, at work. Under Emotions, Discussed, then Anxiety, with feelings of stress, worry, and nervousness and symptoms of panic attacks, difficulty sleeping, and nightmares.
3. Interventions. Cognitive/Behavioral Techniques, then cognitive restructuring, correcting and reframing, negative thoughts and irrational beliefs. Then counseling style.
4. Progress. Each treatment plan goal appears in the note. The therapist marked Goal 1 as progress and Goal 2 as no change, with mood as the reason.
5. Recommendations/Plan. Continue treatment and see a psychiatrist.

Every list has an Add New button for your own keywords and a Notes field. Replicate note from carries selections over from a past session, so the next note for Jerry starts where this one left off. Before signing, Manually edit lets you change any word.

The therapist chose every word. NoteNest just built the sentences.

Why this goes beyond SOAP

Every SOAP element is there, plus a full section SOAP doesn’t ask for.

SOAP	NoteNest section	What it adds
Subjective	Session Content and Themes	Who was present, setting, and each theme discussed
Objective	MSE	A full exam, with evidence for anything outside normal limits
Assessment	Progress	Each treatment plan goal, rated, with the reason
Plan	Recommendations/Plan	Next steps and referrals
No dedicated section	Interventions	Named techniques, what they targeted, and counseling style

Compare that to the SOAP note above. Same session, but only one of them shows what was done and why it mattered.

Why not let AI write it?

AI tools can produce a SOAP note too. They come with three problems a keyword built note doesn’t have.

• It’s a black box. No one can trace an AI sentence back to what happened in session, and the same input can produce different output. If a reviewer asks why the note says something, “the AI wrote it” isn’t an answer.
• HIPAA risk. Most AI scribes record or transcribe sessions and send that data to outside servers. That’s protected health information leaving your control. Before AI touches a single session, the client must consent in writing, and that signed consent has to be on file for every client.
• Insurance audit risk. You sign the note as your own. If AI added something that didn’t happen, that’s documentation of a service you didn’t provide. AI can also be detected with simple software, making you susceptible to higher levels of scrutiny.

NoteNest has none of these issues. No AI, no recordings, and no written consent forms to collect. Just complete, HIPAA compliant therapy notes that say exactly what you chose.

See how NoteNest’s non-AI therapy documentation software works across progress notes, assessments, treatment plans, and discharges.