How to Write ABA SOAP Notes: Step-by-Step With Templates

Applied Behavior Analysis (ABA) SOAP notes are standardized documentation used to record what happened during a therapy session, structured into four clear sections: Subjective, Objective, Assessment, and Plan. 

What does SOAP mean?

SOAP is an acronym for:

• S – Subjective: What the client reported, what caregivers said, and non-measurable observations about mood or cooperation
• O – Objective: Measurable data like trial results, percentages, frequency of behaviors
• A – Assessment: Your interpretation of the session and how the client progressed
• P – Plan: What happens next, including any treatment adjustments and caregiver recommendations

Think of it this way: Subjective = the story; Objective = the numbers; Assessment = what it means; Plan = what's next.

Why accurate SOAP notes matter for your practice

1. Insurance claims depend on the notes: Insurance companies require detailed session documentation before reimbursing you. Missing or vague notes lead to denied claims.

However, different insurance payors have different guidelines for their notes, so you should stay updated with your payors’ requirements.

2. They prove treatment is working: SOAP notes show measurable progress over time, helping justify continued services and secure re-authorizations.
3. They protect you legally: If there's ever a dispute about what happened in a session, your notes are your evidence. Vague documentation leaves you vulnerable.
4. They keep your team aligned: When Registered Behavior Technicians (RBTs), Board Certified Behavior Analysts (BCBAs), caregivers, and providers all have access to clear notes, everyone understands the client's goals and progress.
5. They save time: Organized notes from earlier sessions make it easier to write future entries and spot patterns across sessions.

Breaking down each SOAP section with examples

S – Subjective: Report what you observed (not data)

This section captures non-measurable observations. What did the caregiver say? How did the client seem emotionally? What was the environment like?

What to include:

• Caregiver or client reports about the week
• Client's mood or demeanor upon arrival
• Any changes in behavior outside sessions
• Environmental factors (e.g., tired, sick, excited, etc.)

Example (Good): "Mom reported that the client used more words to request items at home this week. The client arrived calm and was happy to see the therapist."

Example (Poor – Too Vague): "Client was in a good mood today."

Why it matters: Caregivers and insurance reviewers need context. The good example tells a story. The poor example doesn’t, and is not actually useful.

O – Objective: Document measurable data only

This is where you record numbers. How many trials did the client complete? What percentage was correct? How long did a behavior last? What were the frequency counts? Be specific.

What to include:

• Number of trials and accuracy percentages
• Duration of behaviors (in seconds or minutes)
• Frequency counts (how many times a behavior happened)
• Specific intervention responses
• Any challenging behaviors observed

Example (Good): "Client completed 12 out of 15 imitation trials independently (80% accuracy). One instance of non-compliance lasting 35 seconds when transitioning to a new task. Engaged in skill practice for 45 minutes without redirection."

Example (Poor – Too Vague): "Client did well with imitation. He was mostly compliant."

Use exact numbers: "12 out of 15" is better than "most." "35 seconds" is better than "brief tantrum."

A – Assessment: Connect the dots

This section interprets what the data means. Compare the current session’s performance to previous sessions. Did the client improve, decline, or stay the same? What patterns do you notice?

What to include:

• Progress compared to previous sessions
• Whether goals are being met
• Any new concerns or positive trends
• How the client responded to treatment strategies

Example (Good): "Client showed improved compliance during transitions compared to last week. Accuracy on imitation tasks remains at 80%, consistent with recent sessions. The client responded well to visual schedules and needs minimal redirection."

Example (Poor – Too Vague): "Session went okay."

Keep it short: Two to three sentences are usually enough. This isn't where you write your whole clinical opinion, just the key takeaway.

P – Plan: Outline what comes next

This section tells the next RBT, the BCBA, and the parent what should happen in the next session. What strategies worked? What needs to change?

What to include:

• What to continue doing
• Any new targets or strategies to try
• Recommendations for caregivers
• Any notes about treatment modifications
• Follow-up actions for the BCBA

Example (Good): "Continue reinforcement for independent responses during imitation tasks. Next session, introduce new imitation targets with smaller step sizes to prevent frustration. Recommend mom practice visual schedules at home during transitions."

Example (Poor – Too Vague): "Keep doing what we're doing."

Use action words: Continue, introduce, increase, decrease, modify, adjust, implement.

Common ABA SOAP note example (full session)‍

Client Name: Marcus ReeceDate of Birth: 11/07/2019

Date of Birth: 11/07/2019

Session Date: 01/15/2026

Session Time: 10:00 AM – 11:00 AM

Session Duration: 60 minutes

Therapist Name / Credentials: Sarah Cole, RBT

Location: Clinic

Modality: In person

Target Goal: To increase compliance with one-step instructions

CPT Code: 97153

S (Subjective): Mom reported that Marcus used "please" and "thank you" at home twice this week, which is progress. He seemed tired upon arrival but was cooperative. Mom mentioned that transitions at home remain challenging.

O (Objective): Client completed 18 one-step instruction trials with 15 correct responses (83% accuracy). Zero instances of non-compliance. Task engagement time: 45 minutes without redirection. Engaged in play-based activities with preferred toys for reinforcement. No aggressive or self-injurious behaviors observed.

A (Assessment): Client's compliance with one-step instructions improved from 70% last session to 83% this session. The use of visual aids and preferred activity reinforcement appears effective. Client maintained focus for extended periods, suggesting readiness for increased task complexity.

P (Plan): Continue current behavior plan and reinforcement schedule. Next session, introduce two-step instructions to build on current success. Implement visual schedule for transitions at home — provide mom with laminated pictures she can use during morning and evening routines to reduce transition resistance.

Therapist signature: S.C

Date: 01/15/2026

Common SOAP note mistakes (and how to fix them)

Mistake 1: Using vague language instead of specific data

• Vague: "Client did well today"
• Specific: "Client completed 14 of 15 trials with 93% accuracy"

Mistake 2: Mixing subjective and objective

• Subjective: "Client seemed frustrated with the task"
• Objective: "Mom reported frustration at transitions" | O: "One instance of refusal lasting 20 seconds"

Mistake 3: Writing notes days after the session

• Bad practice: Waiting until Friday to write Monday's notes
• Good practice: Write notes within 2 hours while details are fresh.

Mistake 4: Forgetting the Plan section

• No plan: Ending at “A”: Assessment
• Including Plan: Always include specific next steps.

Mistake 5: Using judgmental language

• Judgmental: "Client was stubborn and annoying today"
• Non-judgmental: "Client displayed non-compliance to 3 of 8 requests (62% compliance)"

Mistake 6: Failing to document CPT codes and details

• No details: Missing session date, location, or who was present
• Client and session details: Always include: Client name, DOB, date, time, duration, provider name, CPT code.

ABA SOAP note template (copy and use)

Please note that session note requirements may differ by payor. These requirements should be checked to see if they are met by the simple template below.

CLIENT INFORMATION

Client Name: ___________________________________________

Date of Birth: __________________________________________

Session Date: ___________________________________________

Session Time: ______________ to ______________

Session Duration: _______________________________________

Therapist Name / Credentials: ______________________________

Location: _______________________________________________

Modality:  In Person or Telehealth

CPT Code: ______________________________________________

S (SUBJECTIVE)

[Caregiver reports, client statements, mood, environment]

_____________________________________________________________

_____________________________________________________________

O (OBJECTIVE)

[Measurable data: trial counts, accuracy %, duration, frequency]

Target Behavior: ___________________

Trials Completed: _____ out of _____

Accuracy: _____%

Duration of Session: ___________________

Challenging Behaviors: ___________________

[Specific details and data only]

_____________________________________________________________

_____________________________________________________________

A (ASSESSMENT)

[Progress compared to previous sessions, goal status, patterns]

_____________________________________________________________

_____________________________________________________________

P (PLAN)

[What to continue, what to modify, caregiver recommendations]

_____________________________________________________________

_____________________________________________________________

Therapist Signature: ___________________  Date: ___________________

SOAP notes versus regular session notes: What's the difference?

Key point: Insurance usually requires session notes for billing. SOAP notes are more useful for clinical communication and treatment planning. Many practices use both.

Best practices for writing better SOAP notes

1. Write immediately after the session 

Details fade quickly. Write notes during the session or within 2 hours while everything is fresh. This also reduces errors that come from relying on memory.

2. Use specific numbers, not estimates 

"The client completed 14 of 15 trials" is objective. "The client completed most trials" is vague and won't hold up in an audit.

3. Separate subjective and objective clearly 

Don't mix opinions with data. Label each section so readers understand which one is which.

4. Use active voice and professional language

• Passive: "The client was taught by the therapist"
• Active: "The therapist taught the client..."

5. Always include the Plan 

Every note should end with clear, actionable next steps. This shows you're monitoring progress and adjusting treatment.

6. Use consistent abbreviations 

Establish abbreviations for your practice (e.g., DRO for Differential Reinforcement of Other behavior, NCR for non-contingent reinforcement) and use them consistently.

7. Proofread before submitting 

Typos and inconsistencies can trigger insurance audits or claim denials.

Compliance and documentation standards for ABA SOAP notes 

1. Submit on time 

Submit SOAP notes within 24 to 72 hours of the session, but this differs by payor and state. It’s important to check submission requirements because insurance can deny claims if notes are submitted too late.

2. Pay attention to details 

Vague notes lead to rejected claims. Include specific CPT codes, session dates, duration, and measurable outcomes.

3. Include the right signatures 

Depending on your state and insurance contracts, notes may need signatures from the RBT, supervising BCBA, and sometimes the parent or caregiver. Check your payor requirements.

4. Store old notes 

Record retention requirements vary by state law and insurance contracts. 

Keep all session notes securely stored according to your state's legal requirements and insurance contract terms.

Consult with legal counsel or your compliance officer to determine the specific retention requirements for your jurisdiction and payor contracts.

The Behavior Analyst Certification Board (BACB) requires following applicable laws and maintaining Health Insurance Portability and Accountability Act- (HIPAA-) compliant storage.

Electronic templates reduce errors

When you use the same template for every session, you're less likely to forget information. Many practice management platforms, like Passage Health, offer customizable SOAP templates.

Real-time data entry saves time 

Instead of writing notes from memory after the session, enter data during the session (or immediately after). This creates cleaner, more accurate documentation.

AI-powered session notes

Integrate your real-time data entry into pre-populated SOAP note templates. This means you enter trial data during the session, and narrative summaries are automatically generated based on your session data to help you bill faster.

Centralized documentation prevents errors 

When all providers, supervisors, and caregivers can access the same notes in one place, you avoid duplicate entry and documentation gaps. 

This is especially important when RBTs, BCBAs, and Board Certified Assistant Behavior Analysts (BCaBAs) all contribute to documentation.

Write audit-ready SOAP notes with Passage Health

Writing ABA SOAP notes is easy when you have the customizable templates that Passage Health offers. 

You can prevent data duplication, forgotten session details, and write SOAP notes that pass insurance audits. 

Book a demo to see how Passage Health can help you write thorough ABA SOAP notes.

Frequently asked questions

How long should a SOAP note be? 

Your SOAP notes should be 1 to 2 pages maximum. If you're writing more than that, you're including too much. Keep it concise and focused on what matters.

Can I write SOAP notes on paper, or do I need software? 

You can write SOAP notes on both paper and software, but digital templates are generally more effective. They're easier to organize, search, and submit to payors, but requirements may vary. Paper notes should be scanned and stored securely.

Who needs to write SOAP notes? 

Both RBTs and BCBAs need to write session notes, depending on payor requirements. BCBA notes typically include more clinical interpretation and planning. RBT notes focus more on what the client did and how they responded.

Do I need both SOAP notes and session notes? 

Check your insurance contracts. Most insurers require detailed session notes for billing. SOAP notes are useful for clinical communication and internal team coordination.

What if I made an error in a note I already submitted? 

Don't erase or cross out. Add a new entry with the date and "Addendum" or "Correction to session on [date]" and explain the correction. Keep both versions for the record.

References: 

ABA Coding Coalition. (n.d.). Retrieved November 24, 2026, from https://abacodes.org/

Centers for Medicare & Medicaid Services. (2024, December). Complying with medical record documentation requirements (MLN 909160) [Fact sheet]. Retrieved from https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf 

Podder V, Lew V, Ghassemzadeh S. (Jan 2026; updated as of August 2026). SOAP Notes. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/?utm_source=chatgpt.com