Write it the same day. Record what is needed for care and nothing more; keep it where your service's records rules say, never on a personal device. Print with your browser's Print command; the site's menus are left off the paper.

SOAP progress note

Trainee: ____________________ Placement: ____________________ Date: ____________

Subjective

What the client reported, in their words where it matters
Changes since last session

Objective

What you observed: presentation, mood and affect, engagement
Scores on any measures given today

Assessment

Your clinical impression of progress against the goals
Risk reviewed today, and the outcome

Plan

Homework or tasks agreed
Next session date and focus
Referrals or liaison

Clinician: ______________________________ Date: ______________

Template from PsychologyOrbit (https://psychologyorbit.com/templates/soap-note). Free to print and adapt. No client names, phone numbers, CNIC or hospital numbers, or dates of birth.