SOAP Note Examples
SOAP Note Example for Trauma Therapy
Trauma therapy documentation requires balancing thorough clinical records with appropriate boundaries around trauma content. This example demonstrates how to write a SOAP note for a trauma-focused therapy session.
Subjective
Client reports a reduction in intrusive memories this week from daily to approximately three times. States that the distressing memory targeted in last session's processing feels 'further away' and less activating. Reports one flashback triggered by a loud noise at work, during which they were able to use the grounding technique within about two minutes. Sleep has improved slightly with fewer trauma-related dreams. Denies any new trauma exposure or safety concerns.
Objective
Client appeared calmer than in previous sessions. Less fidgeting and more consistent eye contact observed. During processing work targeting the identified traumatic memory, client's subjective units of distress decreased from six to three out of ten during the session. Client demonstrated effective use of bilateral stimulation technique. Remained within window of tolerance throughout processing without requiring stabilization breaks. Closure exercise was completed successfully.
Assessment
Trauma processing is progressing well. The reduction in intrusive symptoms and improved distress tolerance suggests desensitization is occurring. Client's ability to use grounding during a flashback independently is a significant milestone. Processing appears to be moving through the targeted memory effectively. No adverse reactions to processing have been observed across sessions.
Plan
Continue weekly trauma processing sessions. Target the next memory on the treatment plan hierarchy in the upcoming session. Continue to monitor for adverse inter-session effects. Reinforce grounding and containment techniques. Assign brief daily stabilization exercise. Plan to reassess trauma symptom inventory after completing processing of current target memories. Maintain safety plan.
Trauma Therapy Documentation Practices
Trauma documentation should track symptom changes without including excessive detail about trauma content. Reference specific memories using neutral identifiers rather than detailed descriptions to protect client privacy if records are accessed.
Document the client's distress levels during processing, their ability to stay within the window of tolerance, and any stabilization interventions needed. Track changes in trauma symptom measures across sessions.
Processing Progress Documentation
Record the specific protocol being used, the session number within the protocol, and the target being processed. Note distress ratings at the beginning and end of processing segments to demonstrate treatment progress.
Document any between-session effects reported by the client, including changes in symptoms, new memories emerging, or emotional reactions. This information guides the pace and focus of subsequent processing sessions.
Subjective: [Client's reported symptoms, feelings, and concerns] Objective: [Therapist observations, behavior, appearance, affect] Assessment: [Clinical interpretation and diagnostic impressions] Plan: [Treatment plan, interventions, goals for next session]
Frequently Asked Questions
How do therapists document trauma processing sessions?
Trauma processing documentation includes symptom tracking, distress ratings during processing, window of tolerance observations, protocol adherence, and between-session effects. Trauma content is referenced without excessive detail to protect privacy.
What privacy considerations apply to trauma therapy notes?
Trauma therapy notes should reference traumatic events without detailed descriptions. Use neutral identifiers and focus on clinical observations, symptom changes, and treatment progress rather than narrative trauma content.
Can AI generate trauma therapy SOAP notes?
AI tools like LeafNote can structure raw trauma therapy notes into SOAP format while scrubbing sensitive identifiers before processing. This is particularly valuable for trauma documentation where privacy protection is critical.
Related Resources
Protect privacy while documenting progress
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