Clinical note templates: SOAP, DAP and progress notes

SOAP (Subjective, Objective, Assessment, Plan) suits most therapy sessions. DAP (Data, Assessment, Plan) is common in psychology and counselling because it merges subjective and objective information into one data section. A narrative or goal-based progress note suits NDIS-funded sessions, where each note should tie back to the participant's goals. A template and a worked example for each follow, all using fictional children.

SOAP note template and how to write SOAP notes in Australia

SOAP notes for occupational therapy and speech pathology work well because the objective section holds what you observed and measured, and the plan sets up the next session.

Template

• Subjective: what the child, parent or carer, or teacher reported. Include who was present.
• Objective: what you observed or measured. Tasks, prompts needed, accuracy and any standardised measures.
• Assessment: your clinical interpretation. Progress against the goal, what is working, what is getting in the way.
• Plan: what happens next. Next session focus, home practice given, referrals, and review dates.

Adapt the headings to your discipline and practice policy. Where a funder such as the NDIS applies, add its minimum details (see below).

Worked example: speech pathology, Child C, 4 (fictional)

Session: Individual, 30 minutes, clinic. Child C's mother present throughout. >S: Mother reports Child C has been using more two-word phrases at home, mostly during play with his sister. She says he still gets frustrated at mealtimes when he cannot get his message across. >O: Picture-card and toy-based play task targeting two-word combinations (action plus object). Child C produced two-word combinations in about half of opportunities with a model, for example "push car" and "more juice". Without a model he produced mostly single words. He responded well to a forced choice prompt. >A: Progress towards the goal of using two-word combinations to request and comment. Child C is combining words with support and is beginning to do so spontaneously during play. Modelling and forced choices are effective. >P: Continue the two-word combination target next session using play routines. Taught mother a modelling strategy for mealtimes and provided a short written handout. Review carry-over at the next session. Re-evaluate the goal in six weeks.

The "about half of opportunities" figure is illustrative. Record what you actually observed.

DAP note template for psychology and counselling

A DAP note combines what you heard and what you saw into a single Data section. DAP is common in psychology and counselling, where sessions are mostly conversation.

Template

• Data: what was discussed and observed. Concerns raised, activities used, the child's presentation, parent input and any safety screening.
• Assessment: your formulation for this session. Response to the strategies, progress against the treatment goal, and any change in risk.
• Plan: between-session tasks, the focus of the next session, and any coordination with the family or school.

Worked example: child psychology, Child D, 10 (fictional)

Session: Individual, 50 minutes. Child D attended with a parent, who joined for the last 15 minutes. >D: Child D described feeling worried before school on two mornings this week, mostly about a class presentation. He rated his worry at the start of session as moderate on a simple scale he chose. He practised a slow breathing exercise and identified two worried thoughts, then generated a more balanced thought for each with prompting. A parent joined for the final part of the session. Child D explained the breathing exercise to the parent in his own words. The parent asked how to respond when he becomes worried. >A: Child D is able to name worried thoughts and is beginning to use a balanced thought with support. He used the breathing exercise accurately in session and explained it to his parent. Anxiety is continuing around performance situations. No safety concerns were raised in session. >P: Child D to practise breathing once a day and note one worried thought and balanced thought on a worksheet. Parent given a short, plain-language summary of how to prompt the strategy without taking over. Next session: rehearse the class presentation using graded steps. Review progress against the treatment goal in four sessions.

Progress note template for NDIS-funded sessions

For NDIS-funded sessions the note has two jobs: it is a clinical record, and it is evidence that the support was delivered. The NDIA's record-keeping page lists the minimum identifying information a record should carry, and says case notes should outline the activities and how they relate to the support item and the participant's goals. Notes may also include progress and plans for future sessions.

Template

• Participant name and NDIS number
• Date of support
• Amount, quantity or hours delivered
• Support type and the support item it was billed under
• Goal addressed: the participant's goal or the therapy outcome that supports it
• Activities: what you did, and how it relates to the support item and goal
• Progress: what the participant did, with the level of support needed
• Next session plan

The NDIA says incomplete records in a payment assurance review may mean funds must be repaid. The NDIS website notes it is being updated for new NDIS legislation, so check the current page before you finalise your template.

Worked example: occupational therapy, Child E, 6 (fictional)

Participant: Child E. NDIS number: [recorded here in the real note]. Date: [date]. Hours: 1 hour, at school. Support type: [support item recorded here]. >Goal addressed: Child E will participate in classroom writing and cutting activities with fewer prompts. >Activities: Worked with Child E in the classroom alongside his teacher. Practised a tripod grasp using a short pencil grip, then traced and copied simple letter shapes. Moved to scissor skills, cutting along straight and curved lines drawn on card. The teacher joined for the last ten minutes to see the strategies. >Progress: Child E held the pencil with a functional grasp for most of the writing task after a reminder. He needed hand-over-hand help to start cutting on curves, but cut straight lines independently. The teacher reported he avoids cutting tasks in craft time. >Next session: Continue graded scissor tasks, add a pre-writing warm-up the teacher can run before writing, and review the goal at the next progress report.

SOAP vs DAP vs progress notes: which should you use?

• SOAP: Best for: Therapy sessions with tasks, measures and observations (occupational therapy, speech pathology); Strengths: Separates what was reported from what was observed; clear plan; Watch-outs: Can feel repetitive when sessions are mostly conversation
• DAP: Best for: Talk-based sessions in psychology and counselling; Strengths: Shorter; one data section instead of two; Watch-outs: Observations and reports blend, so be careful to keep facts distinct from interpretation
• Goal-based progress note: Best for: NDIS-funded sessions and reports to funders; Strengths: Ties each session to a goal and support item; easy to build into a progress report; Watch-outs: Needs the identifying details every time; may lack clinical reasoning unless you add it

What makes a good clinical note?

• Written at the time or soon after. If you write it later, say so.
• Objective and factual. Keep interpretation in the assessment.
• Clear on who was present. Record the parent or guardian, a teacher or support worker, and whether anyone joined part way.
• Consent and any AI scribe use recorded. Where a scribe was used, note that the family was told and agreed.
• Corrections dated and visible. Add a dated correction or addendum. Do not overwrite or delete the original entry.
• Enough detail for a colleague to continue care. What was tried, how it went and what comes next.

The Ahpra shared Code of conduct covers health records in section 8.3 and applies to 12 National Boards, including occupational therapy. Psychology and medicine have their own codes. Speech pathologists, who are self-regulated rather than registered with Ahpra, follow Speech Pathology Australia's Code of ethics.

How long do you need to keep clinical notes?

This is general information, not legal advice. In NSW, private health service providers must keep health information for 7 years from the last service for adults. If the information was collected when the person was under 18, it must be kept until they turn 25. This is from the NSW Information and Privacy Commission's fact sheet.

Other states and territories have different rules. Check your own state or territory law and your professional body's guidance before you set a retention policy.

Using an ambient scribe for notes

An ambient scribe can draft a note from a session recording. Ahpra says informed consent will generally be needed for generative AI scribes. It also notes there may be criminal implications if consent is not obtained before recording. The practitioner is responsible for checking the accuracy and relevance of the record.

Ahpra's second case study describes a scribe that added a plausible diagnosis the practitioner never made, in the notes and a referral letter. The Australian Psychological Society's practice guidelines say AI-produced content should be clearly identified. Whatever the tool drafts, the clinician reviews, edits and signs the final note.

In short

• SOAP suits most therapy sessions, DAP suits talk-based psychology and counselling, and goal-based progress notes suit NDIS-funded sessions.
• NDIS records need the participant's name, NDIS number, date, hours and support type, with case notes tied to the support item and goals.
• A good note is timely, factual, records who was present and consent, and shows corrections as dated additions.
• Retention rules differ by state and territory. In NSW it is 7 years for adults, or until age 25 for children.
• If you use an ambient scribe, get consent, check every line and sign the final note yourself.

FAQ

What is the difference between a SOAP note and a DAP note?

A SOAP note has four sections: Subjective, Objective, Assessment and Plan. A DAP note combines the first two into one Data section, which suits talk-based sessions.

What should an NDIS progress note include?

The NDIA lists the participant's name, NDIS number, date of support, amount or hours, and support type as minimum identifying information. Case notes should outline the activities and how they relate to the support item and the participant's goals. Check the current NDIS page before you finalise your template.

Do speech pathologists use SOAP notes?

Yes, SOAP is a common format for speech pathology and occupational therapy sessions because it separates reported information from what you observed and measured. Whichever format you choose, use it consistently across your service.

Can I fix a mistake in a clinical note?

Add a dated correction or addendum and leave the original entry visible. Check your professional body's guidance and practice policy for the exact steps.

Syntropic Health's ambient scribe drafts the session note inside the case, and the clinician reviews, edits and signs it.

Sources

• ndis.gov.au
• ndis.gov.au
• ahpra.gov.au
• ahpra.gov.au
• ahpra.gov.au
• ahpra.gov.au
• psychology.org.au
• ipc.nsw.gov.au
• speechpathologyaustralia.org.au