SOAP Note Example
Psychotherapy SOAP Note Example
Below is a complete SOAP note example for an individual psychotherapy session using Eye Movement Desensitization and Reprocessing (EMDR) therapy to treat post-traumatic stress disorder. This example demonstrates proper documentation of EMDR-specific protocols, target memory identification, Subjective Units of Disturbance (SUD) and Validity of Cognition (VOC) scales, bilateral stimulation, and phase progression.
Complete Psychotherapy Note
SUBJECTIVE:
Client is a 34-year-old male presenting for his 10th individual psychotherapy session (weekly frequency). Diagnosed with Post-Traumatic Stress Disorder (F43.10) related to a motor vehicle accident 14 months ago in which the client was the restrained driver struck head-on by a vehicle that crossed the center line. Client sustained a fractured left clavicle, three fractured ribs, and a mild traumatic brain injury. The other driver was fatally injured. Client reports PTSD symptoms have been "somewhat better overall" since initiating EMDR at session 6, but this past week was particularly difficult. States he had two nightmares about the accident — one involving the sound of the collision and one in which he saw the other driver's face — compared to 4-5 nightmares per week at intake. Reports that driving remains his most significant trigger: he avoids highway driving entirely and limits local driving to essential errands, always taking back roads. Describes a specific triggering event this past week — a car in the adjacent lane swerved slightly toward his lane and he experienced an intense startle response with heart pounding, sweating, gripping the steering wheel, and pulling over to the shoulder where he sat for 15 minutes before he could continue driving. Reports persistent hypervigilance while driving, constantly scanning other vehicles for erratic movement. Endorses ongoing difficulty with concentration at work (software engineer), intrusive images of the collision that occur 2-3 times daily (down from 8-10 times daily at intake), emotional numbing in his relationship with his partner ("I know I love her but I can't feel it the way I used to"), and exaggerated startle response to loud unexpected sounds. Sleep has improved from 3-4 hours per night at intake to 5-6 hours, though he still avoids sleeping on his left side due to a conditioned association with the clavicle pain. PCL-5 (PTSD Checklist) score completed prior to session: 42 (intake score: 61; score at session 6 before starting EMDR: 55; clinically significant change threshold: 10-point reduction). Client denies suicidal ideation, self-harm, and homicidal ideation. Current medications: prazosin 2 mg at bedtime (prescribed by psychiatrist Dr. Okafor for trauma-related nightmares), sertraline 100 mg daily (started 3 months ago, dose increased from 50 mg to 100 mg 6 weeks ago). No alcohol or substance use — client reports he stopped drinking entirely after the accident because "even one beer makes the flashbacks worse."
OBJECTIVE:
EMDR session — Phase 4 (Desensitization) and Phase 5 (Installation), continuing reprocessing of Target Memory #1 from previous session. Target memory #1: the moment of impact — seeing headlights crossing the center line directly toward him, the sound of the collision, the smell of airbag deployment, and the visual image of the other driver's vehicle immediately after impact. Negative cognition: "I am powerless." Positive cognition: "I can handle what comes." Validity of Cognition (VOC) rating for positive cognition at start of session: 3/7 (1 = completely false, 7 = completely true; previous session ended at VOC 3/7). Subjective Units of Disturbance (SUD) at start of session: 5/10 (0 = no disturbance, 10 = worst possible; initial SUD at first targeting session was 9/10; previous session ended at SUD 6/10). Emotions identified at session start: fear, guilt, helplessness. Physical sensation location: chest tightness, left shoulder tension, clenched jaw. Bilateral stimulation (BLS): horizontal eye movements using therapist's fingers, sets of 24-30 passes at moderate speed. Desensitization phase: Set 1 — client instructed to hold the target image (headlights approaching), the negative cognition ("I am powerless"), and the body sensation (chest tightness). After BLS, client reported the image shifted to "everything going silent right before impact" and rated the disturbance at 5/10. New material emerged — the thought "I should have reacted faster." Set 2 — BLS applied to the new cognition. Client reported a memory of sitting in the wrecked car hearing emergency sirens, followed by the thought "but I couldn't have reacted — it happened too fast." SUD: 4/10. Therapist noted client's breathing deepened and jaw tension visibly released. Set 3 — client reported the image became "further away, like watching it on a screen instead of being in it." Spontaneously stated, "It wasn't my fault. There was nothing I could do — he crossed the line." SUD: 3/10. Emotions shifted from fear and guilt to sadness. Set 4 — BLS applied with focus on the sadness. Client became tearful and stated, "I feel sad for him — for the other driver. He died and I survived." SUD: 2/10. Therapist noted a significant shift from self-blame to grief, indicating adaptive processing. Set 5 — client reported the image of the headlights was still present but "doesn't have the same charge." SUD: 1/10. Set 6 — SUD: 1/10 (stable). Client stated, "I can look at it now. It was terrible, but I survived it and I'm still here." SUD confirmed at 1/10 — desensitization phase considered complete for this target. Installation phase (Phase 5): positive cognition "I can handle what comes" reassessed — client reported it felt partially accurate but wanted to modify it to "I survived and I am safe now." Revised positive cognition: "I survived and I am safe now." VOC for revised positive cognition: 5/7. BLS applied while client held the target memory paired with the revised positive cognition. After 2 sets: VOC increased to 6/7. After 2 additional sets: VOC 6/7 (stable). Installation considered adequately progressed — not yet at 7/7, will continue at next session. Body scan (Phase 6): client instructed to hold the target memory and positive cognition while scanning for residual body sensations. Reported mild residual tension in left shoulder. BLS applied — tension reduced but did not fully resolve. Therapist noted this may be related to the somatic memory of the clavicle fracture and will revisit. Closure (Phase 7): guided visualization (safe/calm place — client's image is sitting on his back porch at dusk listening to crickets) used to return to baseline. Post-closure SUD: 1/10. Client's affect at session end was calm with full range, appropriate eye contact, and reflective tone. Oriented to present time, place, and person. Mental status: appearance appropriate, behavior cooperative, speech normal rate and volume, mood "lighter than when I came in," affect congruent and full range, thought process linear and goal-directed, thought content — no delusions, no obsessional thinking, insight improved within session, judgment intact. Risk assessment: denies SI, HI, and self-harm; no substance use; protective factors include supportive partner, stable employment, active engagement in treatment, and future-oriented thinking (discussed wanting to drive to visit his parents this summer). Risk level: low.
ASSESSMENT:
Client meets DSM-5 criteria for Post-Traumatic Stress Disorder (F43.10) with prominent re-experiencing symptoms (nightmares, intrusive images, physiological reactivity to trauma cues), avoidance behaviors (highway driving, back roads only, alcohol cessation as avoidance of flashback triggers), negative alterations in cognition and mood (emotional numbing, guilt related to the other driver's death), and hyperarousal (hypervigilance while driving, exaggerated startle, sleep disruption). The PCL-5 reduction from 61 at intake to 42 at session 10 represents a 19-point decrease, which exceeds the clinically significant change threshold of 10 points and indicates meaningful treatment response. Of note, the majority of this improvement (13 points) occurred after initiating EMDR at session 6, suggesting that the phase-based trauma processing is the primary active treatment mechanism above and beyond the stabilization and psychoeducation provided in sessions 1-5. Today's session achieved significant desensitization of Target Memory #1 — SUD decreased from 5/10 at session start to 1/10 (from an initial 9/10 at first targeting), indicating near-complete desensitization of this specific memory node. The adaptive processing observed during reprocessing was clinically significant: the spontaneous cognitive shift from "I should have reacted faster" (self-blame) to "there was nothing I could do — he crossed the line" (accurate attribution) to grief for the other driver represents a natural and healthy reprocessing progression from maladaptive guilt to adaptive mourning. The client's ability to modify the positive cognition from "I can handle what comes" to "I survived and I am safe now" reflects increasing self-awareness and active participation in the therapeutic process. The VOC of 6/7 for the revised cognition indicates that installation is nearly complete but requires further strengthening. Residual left shoulder tension during the body scan may represent a somatic trauma memory linked to the clavicle fracture that will require separate targeting. Overall prognosis is good — the client is responding well to EMDR, the trauma is a single-incident adult-onset event (favorable for EMDR outcomes), and he has strong protective factors.
PLAN:
Continue weekly individual psychotherapy with EMDR as the primary treatment modality. Next session agenda: (1) re-access Target Memory #1 and check SUD — if SUD remains at 0-1, complete installation of the positive cognition (goal: VOC 7/7) and conduct a full body scan to clear any residual somatic disturbance including the left shoulder tension; (2) if Target Memory #1 is fully resolved (SUD 0, VOC 7, clean body scan), introduce Target Memory #2 from the trauma memory hierarchy — identified during case conceptualization as the moment of hearing that the other driver had died (currently rated SUD 8/10, associated negative cognition: "It should have been me"). Address survivor guilt as a distinct trauma node that may require its own targeting sequence. EMDR future template to be developed once all past-memory targets are resolved — specifically targeting the feared scenario of highway driving to prepare for in-vivo exposure. Behavioral component: discuss graded driving exposure hierarchy at next session — beginning with riding as a passenger on the highway for a short distance (one exit), progressing to driving on the highway during low-traffic hours with the partner present, and advancing toward independent highway driving. This behavioral exposure is designed to complement the EMDR reprocessing by providing real-world disconfirmation of the danger cognitions. Continue prazosin 2 mg at bedtime and sertraline 100 mg daily — recommend the client attend his next psychiatry appointment with Dr. Okafor (scheduled 03/18/2026) to review the nightmare frequency reduction and discuss whether prazosin dose adjustment is warranted. Administer PCL-5 every 4 sessions (next at session 14) to track symptom trajectory. Long-term treatment goals: reduce PCL-5 to below the clinical cutoff of 33, resolve avoidance of highway driving, reduce nightmare frequency to 0-1 per week, decrease intrusive images to less than 1 per day, and restore emotional engagement in the partner relationship. Anticipated treatment duration: 8-12 additional sessions depending on the number of trauma nodes requiring reprocessing. Safety plan not indicated — risk level remains low with strong protective factors. If client experiences a significant increase in distress between sessions related to activated trauma material, he has been instructed to use the safe/calm place visualization and to contact the clinic if symptoms become unmanageable.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
In psychotherapy SOAP notes for EMDR, the subjective section should document the client's self-reported PTSD symptom status since the last session, including specific symptom clusters (re-experiencing, avoidance, negative cognitions and mood, hyperarousal) with concrete examples and frequency counts. Include any triggering events that occurred between sessions with enough detail to understand the client's current trauma reactivity level. The PCL-5 score provides a validated, quantifiable symptom measure that should be tracked over time with comparison to intake and prior scores. Document medication status, substance use, and risk screening. This section establishes the clinical context for the EMDR processing that will be documented in the objective section and helps the clinician assess whether the client is stable enough to proceed with trauma reprocessing.
Objective
EMDR documentation requires detailed phase-by-phase recording that captures the specific target memory, the negative and positive cognitions, the SUD and VOC ratings at the start and end of each phase, the type of bilateral stimulation used, and the content and cognitive shifts that emerge during each set of BLS. Document the number of sets, the client's reported imagery, cognitions, emotions, and body sensations after each set, and any spontaneous adaptive processing — this is the evidence that the therapy is producing change. Record the body scan findings and the closure procedure used. Include a standard mental status exam and risk assessment. This level of detail is unique to EMDR documentation and serves multiple purposes: it demonstrates fidelity to the EMDR protocol, provides a clinical record that allows any EMDR-trained clinician to continue the work, and tracks the measurable within-session change that justifies the treatment modality.
Assessment
The psychotherapy assessment for EMDR should interpret the session's reprocessing in the context of the overall trauma treatment. Analyze the PCL-5 trajectory and attribute symptom changes to specific treatment phases when possible (stabilization vs. active EMDR reprocessing). Interpret the qualitative content of the reprocessing — identify the cognitive and emotional shifts that occurred (self-blame to accurate attribution to grief) and explain why these represent adaptive processing rather than avoidance or looping. Note any incomplete processing (VOC not yet at 7, residual body scan findings) and hypothesize what may account for it (somatic memory of the injury). Provide a prognosis based on the nature of the trauma (single-incident vs. complex), the client's response to EMDR so far, and the remaining targets in the treatment hierarchy.
Plan
The EMDR treatment plan should specify the next steps within the EMDR protocol — which phase will be addressed, which target memory is next in the hierarchy, and what the decision criteria are for advancing (SUD 0, VOC 7, clean body scan). Include the future template and any behavioral components that will complement the reprocessing, such as graded in-vivo exposure for avoidance behaviors. Coordinate with the prescribing psychiatrist regarding medication adjustments informed by symptom changes. Specify the schedule for readministering the PCL-5 and define the treatment endpoint using a validated cutoff score. Estimate the remaining treatment duration based on the number of unprocessed trauma nodes. This structured plan demonstrates that the therapy is following an evidence-based protocol with defined endpoints, which distinguishes EMDR documentation from open-ended process-oriented psychotherapy notes.
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