Template library · Session notes
Session SOAP Note template
Subjective, Objective, Assessment, and Plan note for documenting an individual session.
- 14 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- ClientText
- Session dateDate
- DurationText
- ModalityChoice
- Session #Text
Subjective
- SubjectiveText
- Client's report of their current state, concerns raised, and events since the last session.
Objective
- ObjectiveText
- Observable presentation — appearance, affect, mood, speech, thought process, behavior during session.
Assessment
- AssessmentText
- Clinical impression, progress toward goals, risk status, and any updates to working diagnosis.
Plan
- Interventions used this sessionText
- Homework / between-session tasksText
- Next session focusText
- Next appointmentDate
- SignatureText
- DateDate
When to use it
Write a session note after each appointment, while it is fresh, so the record of what happened and what comes next is complete.
How it works in MyWellOps
- Open the client’s record and start a note from the template.
- Write it yourself, or record the session with the client’s consent and edit the draft AI Notes gives you.
- The note is saved on the client’s record, private to your practice.
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