- Is this SOAP note template HIPAA-compliant?
- This tool runs entirely in your browser — no data is sent to any server, stored in the cloud, or transmitted anywhere. Session data saved via the "Save Session" button lives only in your browser's localStorage on your local device. However, HIPAA compliance also depends on who has access to your device and browser. Use this on a personal or clinic-managed computer, lock your screen when stepping away, and export PDFs to your clinic's compliant EHR or secure file system. The tool itself does not create, receive, maintain, or transmit ePHI on any server.
- What should I write in each SOAP section for therapy?
- Subjective: Capture what the client tells you — chief complaint, mood self-rating, stressors, notable quotes. Objective: Describe your clinical observations — appearance, affect (flat, constricted, appropriate), behavior in session, standardized scale scores (e.g. PHQ-9 = 14), and engagement level. Assessment: Link S and O to your clinical impression — is the client progressing toward treatment goals? Any change in diagnosis or risk level? Plan: List interventions (CBT thought records, EMDR, DBT skills), any homework assigned, next session date, referrals, and medication or crisis-line information if relevant.
- Can I use this template for different therapy modalities?
- Yes. The SOAP structure is modality-agnostic and is used across CBT, DBT, psychodynamic, solution-focused, EMDR, and integrative approaches. Simply adapt the language in each section to reflect your clinical style and the interventions relevant to your modality. The Plan section is a good place to name the specific technique used (e.g., "Conducted BLS bilateral stimulation for traumatic memory processing — Phase 4 desensitization").