SOAP Notes vs Progress Notes: Key Differences Explained
Written by SOAPNoteAI Editorial Team · Updated June 2026
"Progress note" and "SOAP note" are often used interchangeably — and that creates real confusion for new clinicians, students, and anyone switching between specialties. This guide explains the relationship between these two terms, when each format is appropriate, and how to choose the right documentation style for your clinical setting.
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The Short Answer
A SOAP note is a type of progress note. The term "progress note" describes any clinical documentation that tracks a patient's condition over time during ongoing care. SOAP is the most widely used format for writing those progress notes.
Think of it this way:
- Progress note = the category (like "car")
- SOAP note = the format within that category (like "sedan")
Other progress note formats include DAP, BIRP, GIRP, and narrative notes. All of these are types of progress notes. SOAP is simply the most common and most widely taught.
What Is a Progress Note?
A progress note is any clinical documentation that:
- Records a patient encounter or therapeutic session
- Updates the patient's status since the last visit
- Documents clinical reasoning and treatment decisions
- Becomes part of the permanent medical record
Progress notes serve multiple purposes simultaneously:
- Clinical continuity: allows any provider to understand the patient's history at a glance
- Legal documentation: creates a contemporaneous record of care decisions
- Billing support: substantiates the services billed to payers
- Communication: informs other members of the care team
What Is a SOAP Note?
A SOAP note organizes a clinical encounter into four labeled sections:
| Section | Contains | Written By |
|---|---|---|
| Subjective | Patient-reported symptoms, history, concerns | What the patient says |
| Objective | Measurable clinical findings, vitals, labs, exam | What you observe and measure |
| Assessment | Diagnosis, differential, clinical impression | Your clinical conclusion |
| Plan | Treatment, orders, education, follow-up | What you will do |
The SOAP format was developed by Dr. Lawrence Weed at the University of Vermont in the 1960s as part of the Problem-Oriented Medical Record (POMR). It has since become the global standard for clinical documentation across nearly all healthcare disciplines.
SOAP notes are used in:
- Primary care and family medicine
- Emergency medicine
- Physical therapy and occupational therapy
- Chiropractic and acupuncture
- Nursing (often as SOAPIE)
- Veterinary medicine
- Pharmacy (medication therapy management)
- Most hospital inpatient settings
For a complete guide on writing each section, see our step-by-step SOAP note guide.
Other Progress Note Formats
DAP Notes (Data, Assessment, Plan)
DAP notes combine the Subjective and Objective information into a single Data section, followed by Assessment and Plan.
Best for: Individual therapy, counseling, case management, and settings where there is no meaningful physical exam data.
| Section | Contains |
|---|---|
| Data | Both patient-reported information and therapist observations — combined |
| Assessment | Therapist's clinical impression, diagnosis |
| Plan | Treatment plan, goals, interventions for next session |
When to choose DAP over SOAP: If your clinical work involves primarily talk therapy and you have no vitals, labs, or physical findings to document, DAP avoids the awkward empty "Objective" section that SOAP would create. Mental health therapists, counselors, and social workers commonly use DAP.
See our full DAP notes guide for examples and templates.
BIRP Notes (Behavior, Intervention, Response, Plan)
BIRP notes are organized around the therapeutic process rather than the clinical encounter structure.
| Section | Contains |
|---|---|
| Behavior | Patient's presentation, mood, affect, reported symptoms |
| Intervention | What the therapist did: techniques, modalities used |
| Response | How the patient responded to the intervention |
| Plan | Next session goals, homework, treatment adjustments |
Best for: Behavioral health, addictions treatment, community mental health, and managed care settings.
See our full BIRP notes guide for examples and templates.
GIRP Notes (Goal, Intervention, Response, Plan)
Similar to BIRP, but the opening section focuses on the specific treatment goal being addressed rather than patient behavior/presentation. Common in substance use treatment and structured therapeutic programs.
Narrative Progress Notes
Some settings (particularly psychiatry, emergency medicine, and certain specialist consultations) use a narrative format with no rigid labeled sections. The provider writes a flowing paragraph covering the encounter. These are flexible but harder to audit and harder to review quickly.
Side-by-Side Comparison
| Feature | SOAP | DAP | BIRP | Narrative |
|---|---|---|---|---|
| Sections | 4 (S/O/A/P) | 3 (D/A/P) | 4 (B/I/R/P) | None |
| Separates subjective/objective | Yes | No | No | No |
| Documents intervention process | No | No | Yes | Optional |
| Best setting | Medical, PT/OT, interdisciplinary | Mental health, counseling | Behavioral health, addictions | Psychiatry, ED |
| EHR support | Universal | Common | Common | Universal |
| AI documentation tools | Excellent | Good | Good | Variable |
| Insurance billing support | Excellent | Good | Good | Fair |
Which Format Is Right for You?
Use SOAP Notes When:
- You see patients in a medical, physical therapy, or interdisciplinary setting
- Your encounters include vitals, physical exam findings, labs, or imaging
- You bill using E/M (Evaluation and Management) codes
- You work in primary care, urgent care, emergency medicine, or any surgical specialty
- You're a nurse, NP, or PA doing clinical assessments
- Your EHR has separate fields for physical exam and clinical findings
Specialty-specific SOAP note guides:
Use DAP Notes When:
- You are a therapist or counselor in a mental health or substance use setting
- Your documentation captures talk therapy without physical assessment
- Your insurance payers require DAP format (check your contracts)
- You are supervised under a licensed clinician and your supervision documentation requires it
Use BIRP Notes When:
- You work in community mental health, managed care, or addictions treatment
- Your documentation is reviewed by case managers for authorization
- You need to clearly demonstrate treatment progress (Intervention + Response) for utilization review
- Your facility or state documentation standards specify BIRP
SOAP Notes in 2026: AI-Assisted Documentation
One major reason SOAP notes remain dominant is that AI documentation tools are optimized for the SOAP structure. Ambient AI scribes (including those built into Epic, athenahealth, and Oracle Health) generate SOAP-formatted notes from recorded patient encounters.
Key findings from 2026 research:
- The Philips Future Health Index 2026 found AI tools save clinicians the equivalent of more than 16 working days per year in documentation time
- A multi-site study published in JMIR Medical Informatics found 27% reduction in documentation time using ambient AI scribes
- Mass General Brigham reported a 21.2% reduction in burnout after 84 days of ambient AI use
For AI-assisted SOAP note generation, SOAPNoteAI is a HIPAA-compliant tool (signed BAA) that works across all clinical disciplines. See our AI SOAP notes guide for details on how AI documentation works.
Templates: Quick Reference
SOAP Note Template
SUBJECTIVE: Chief Complaint: [Patient's primary concern in their own words] History of Present Illness: [Onset, location, duration, character, aggravating/relieving factors, associated symptoms] Medical/Surgical History: [Relevant past history] Medications: [Current medications, doses, frequency] Allergies: [Medications and reactions] Social History: [Relevant lifestyle factors] Review of Systems: [Pertinent positives and negatives]
OBJECTIVE: Vital Signs: BP / HR ___ RR ___ Temp ___°F SpO2 ___% Weight ___ General: [Patient appearance and affect] Physical Exam: [System-by-system findings, pertinent positives and negatives] Labs/Imaging: [Relevant results with dates]
ASSESSMENT: Primary Diagnosis: [Diagnosis with ICD-10 code] Differential Diagnoses: [Additional considerations] Clinical Reasoning: [How findings support the assessment]
PLAN:
- [Medication ordered/adjusted — drug, dose, frequency, duration]
- [Tests ordered — with rationale]
- [Referrals — specialty and urgency]
- [Patient education provided]
- [Follow-up — timeframe and instructions]
DAP Note Template
DATA: Patient presented [affect/mood]. Reports [patient's statements about current status]. Currently [work/school/relationship status if relevant]. Denies [safety concerns/substance use if applicable].
ASSESSMENT: [DSM-5 diagnosis]. Patient continues to [progress/struggle with] [treatment goals]. Risk assessment: [current risk level and basis].
PLAN: Continue [current treatment modalities]. Focus for next session: [specific therapeutic focus]. Homework/between-session tasks: [if assigned]. Next appointment: [date/frequency].
BIRP Note Template
BEHAVIOR: Client presented [on time/late], [groomed/disheveled], mood [mood description], affect [affect description]. Client reported [key presenting issues this session].
INTERVENTION: Utilized [CBT/DBT/motivational interviewing/other modality]. Explored [topic/theme]. Practiced [skill/technique]. Addressed [specific issue].
RESPONSE: Client [engaged/resisted/was ambivalent] to interventions. Demonstrated [insight/skill practice/coping strategy]. Notable response: [specific observation].
PLAN: Continue [current frequency] sessions. Client will practice [between-session skill/homework]. Next session will focus on [planned topic]. [Safety plan reviewed/updated if applicable].
Frequently Asked Questions
Frequently Asked Questions
A SOAP note is a structured progress note format organized into four sections: Subjective (patient-reported symptoms), Objective (clinical findings), Assessment (diagnosis), and Plan (treatment). The term 'progress note' is broader — it refers to any documentation of a patient's care over time, of which SOAP is one format. Other progress note formats include DAP (Data, Assessment, Plan), BIRP (Behavior, Intervention, Response, Plan), and narrative formats. In many clinical settings, SOAP notes ARE progress notes; the terms are used interchangeably.
Use SOAP notes for medical and interdisciplinary settings where the Objective section (vitals, labs, physical exam findings) is clinically important — primary care, urgent care, inpatient medicine, physical therapy, and most specialty practices. Use DAP notes in mental health and counseling settings where there is no meaningful objective/physical exam data: individual therapy, group counseling, case management. DAP combines all data (both subjective reports and therapist observations) into a single Data section, making it more efficient for talk-therapy contexts.
Yes, SOAP notes are part of the medical record and are legal documents. They may be subpoenaed in malpractice cases, reviewed in licensing investigations, audited for billing compliance, and accessed under HIPAA by patients themselves. Every entry should be accurate, timely, signed, and never altered after signing (corrections must be documented as amendments). The quality of your SOAP notes directly affects your legal protection: a note that documents your clinical reasoning and patient communication is far stronger evidence than an incomplete or vague one.
Yes, SOAP notes can be used for therapy sessions, and many therapists do use them — especially those working in integrated care or medical settings. However, DAP and BIRP formats are more common in pure therapy contexts because they better reflect the nature of therapeutic work (there are fewer 'objective' data points like lab values). For therapists in community mental health billing through insurance, the format required is often specified by the payer. Always check your payer contracts and state licensing board documentation standards.
SOAP notes are organized around the clinical encounter structure: what the patient said, what you found on exam, what you diagnosed, what you'll do. BIRP notes are organized around the therapeutic intervention structure: what the patient's Behavior/presentation was, what Intervention you used, how the patient Responded, and what the Plan is. BIRP is most common in behavioral health, addictions treatment, and community mental health settings. SOAP is more versatile and is used across all clinical disciplines.
Nurses use both, depending on the setting and documentation system. In many hospitals, nurses write structured nursing notes that follow a modified SOAP or SOAPIE (Subjective, Objective, Assessment, Plan, Implementation, Evaluation) format within the EHR. In outpatient and home health settings, nursing progress notes may follow SOAP format or may be narrative. The specific format is typically determined by facility policy and the EHR's charting structure. AI documentation tools are increasingly helping nurses complete structured notes faster.
Most major EHRs support SOAP-structured notes, though the specific fields vary. Epic uses a SmartForm structure with separate Subjective, Objective (linked to flowsheets), Assessment, and Plan fields. athenahealth uses a similar encounter note structure. Oracle Health (Cerner) has structured note templates that can follow SOAP. Many EHRs also allow free-text narrative notes. As of 2026, EHR-native ambient AI tools in Epic, athenahealth, and Oracle Health auto-populate SOAP-structured notes from recorded encounters.
Summary
- Progress note = any clinical documentation of patient care over time (broad term)
- SOAP note = a four-section progress note format (Subjective, Objective, Assessment, Plan)
- SOAP is the most widely used format in medicine, PT/OT, nursing, and interdisciplinary care
- DAP and BIRP are preferred in mental health and behavioral health settings
- In 2026, AI documentation tools have made SOAP note completion significantly faster without sacrificing accuracy
For specialty-specific guidance, explore our complete SOAP note guides library.
Medical Disclaimer: This content is for educational purposes only and should not replace professional medical judgment. Always consult current clinical guidelines and your institution's policies.