Trauma is one of the most common reasons people seek therapy, counseling, and mental health support. Many clients experience trauma from childhood, relationships, accidents, violence, war, medical events, or sudden loss. Trauma can affect sleep, emotions, relationships, and even physical health. For professionals, writing a trauma SOAP note can feel hard. Trauma work includes sensitive topics. It also includes symptoms like dissociation, panic, flashbacks, and self-blame. You must document carefully, clearly, and ethically.

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This blog explains how to write a trauma SOAP note. We will also share multiple trauma SOAP note examples you can use as guidance.

What Is a Trauma SOAP Note?

A SOAP note is a clinical note format used in healthcare and mental health. SOAP stands for: S = Subjective, O = Objective, A = Assessment, P = Plan. A trauma SOAP note is a SOAP note written for a client who has trauma symptoms or a trauma-related diagnosis. This includes PTSD, acute stress disorder, complex trauma, and trauma-related anxiety or depression.

The goal is to document what the client reports, what you observe, your clinical judgment, and the next steps in treatment.

Why Trauma SOAP Notes Matter

Trauma documentation is important because trauma symptoms can change quickly. A client may appear stable in one session and then have strong flashbacks or panic in the next. SOAP notes help track progress and safety over time. SOAP notes also support clinical communication. If a client changes providers, your note helps the next professional understand what happened, what was tried, and what worked.

Most importantly, trauma SOAP notes protect the client and the clinician. Clear documentation supports ethical care, treatment planning, and risk management.

Trauma SOAP Notes: The Most Common Mistakes

One common mistake is writing too much detail about the trauma event. In most cases, you do not need graphic details. You should focus on symptoms, impact, and treatment work.

Another mistake is using vague statements like “client is doing better.” Instead, document specific signs like “sleep improved from 3 hours to 6 hours” or “panic reduced from daily to twice per week.”

A third mistake is not documenting safety. Trauma clients may have self-harm thoughts, suicidal ideation, or unsafe relationships. If safety is discussed, it should be documented clearly.

Trauma SOAP Note Writing Basic Rules

When writing trauma SOAP notes, use clear language and avoid judgment. Write what the client said, what you saw, and what you did. Avoid guessing. Keep the note factual and neutral. For example, instead of “client is dramatic,” write “client cried throughout session and reported feeling overwhelmed.” Also, document trauma work carefully. If you used grounding, EMDR preparation, exposure work, or cognitive restructuring, include it in the note.

Subjective (Trauma SOAP Note)

What Goes in the Subjective Section?

The Subjective section is what the client reports. It includes symptoms, feelings, and personal experiences. In trauma care, subjective data often includes:

• Flashbacks
• Nightmares
• Panic attacks
• Avoidance
• Hypervigilance
• Dissociation
• Shame, guilt, or fear
• Sleep issues
• Relationship problems

This section should sound like the client’s voice, but you can still write it in professional language.

Subjective: Best Practice for Trauma Notes: Trauma clients may share painful details. You do not need to write every detail. Instead, focus on the theme and the emotional impact. Also include changes since the last session. Trauma recovery often happens in small steps, so tracking small changes is important. If the client reports triggers, document them. Triggers help guide treatment and safety planning.

Subjective Example Phrases (Trauma)

Here are simple phrases you can use:

• “Client reports increased nightmares this week.”
• “Client states they felt unsafe after seeing a reminder of the trauma.”
• “Client reports flashbacks occurred 3 times in the past 7 days.”
• “Client reports avoidance of driving since the accident.”
• “Client states they feel guilty and blame themselves.”

Objective (Trauma SOAP Note)

What Goes in the Objective Section?

The Objective section is what you observe during the session. It includes:

• Appearance and behavior
• Mood and affect
• Speech
• Eye contact
• Psychomotor activity
• Orientation
• Signs of dissociation
• Signs of panic or distress

It may also include results from screening tools if used (like PTSD checklist, PHQ-9, GAD-7), but keep it brief.

Objective: Trauma-Specific Observations: Trauma clients may appear calm but still be distressed internally. Still, you should document what you can observe. Trauma can show up in the body through shaking, sweating, rapid breathing, or freezing. Dissociation is also important to document. Examples include blank staring, slowed speech, confusion, or feeling “not present.” If grounding was used, you can document how the client responded.

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Objective Example Phrases (Trauma)

• “Client appeared tearful and tense.”
• “Client maintained minimal eye contact.”
• “Client’s hands were shaking when discussing triggers.”
• “Client became quiet and stared into space for ~30 seconds; grounding was used.”
• “Client was oriented x4 and able to return to baseline by end of session.”

Assessment (Trauma SOAP Note)

What Goes in the Assessment Section?

The Assessment section is your clinical judgment. This is where you connect symptoms to diagnosis and progress. You may include:

• Trauma symptom severity
• Progress toward goals
• Client insight and readiness
• Risk level (low/moderate/high)
• Working diagnosis or clinical impression

This section should not be overly long. It should be clear and focused.

Assessment: How to Write It Safely: In trauma notes, avoid writing strong conclusions without evidence. Instead of “client is lying,” document inconsistencies in a neutral way if needed. Also avoid blaming language. Trauma clients often already blame themselves. Your note should reflect a trauma-informed approach. If risk is assessed, document the result clearly. Example: “Client denies suicidal ideation. No current plan or intent. Risk assessed as low.”

Assessment Example Phrases (Trauma)

• “Symptoms consistent with PTSD remain present, including nightmares and hypervigilance.”
• “Client shows mild improvement in grounding skills.”
• “Client continues to avoid trauma reminders, impacting daily functioning.”
• “Client reports reduced panic episodes compared to last session.”
• “Risk level assessed as low at this time.”

Plan (Trauma SOAP Note)

What Goes in the Plan Section?

The Plan section includes what you will do next. It often includes:

• Next session focus
• Homework or coping skills practice
• Safety plan steps
• Referrals (psychiatry, medical, support group)
• Frequency of sessions
• Crisis resources if needed

The plan should be practical and realistic.

Plan: Trauma Treatment Must Be Structured

Trauma therapy works best when it is structured. Many clinicians follow phases:

1. Safety and stabilization
2. Processing trauma memories
3. Integration and future growth

Even if you do not write these phases, your plan should reflect stability first. If a client is not stable, deep trauma processing may not be appropriate.

Plan Example Phrases (Trauma)

• “Continue weekly therapy sessions.”
• “Practice grounding exercise daily for 5 minutes.”
• “Review coping plan for flashbacks next session.”
• “Explore trauma narrative only after stabilization improves.”
• “Provide referral for psychiatric evaluation for sleep medication.”

Trauma SOAP Note Examples (PTSD)

PTSD from Relationship Violence

S (Subjective): Client reports increased anxiety and nightmares over the past week. Client states they had 4 nightmares related to past relationship violence. Client reports they avoided going to a friend’s house because the neighborhood reminded them of the trauma. Client states, “I keep thinking it was my fault.” Client reports sleep averaging 4–5 hours per night. Client denies suicidal ideation.

O (Objective): Client arrived on time and appeared tense. Client was tearful while discussing trauma triggers. Speech was clear but slightly pressured when describing nightmares. Affect was anxious and constricted. Client was oriented x4. No signs of psychosis observed. Client used grounding (5-4-3-2-1) and was able to reduce distress by end of session.

A (Assessment): Client continues to experience PTSD symptoms including nightmares, avoidance, hyperarousal, and negative self-blame. Client shows moderate insight and willingness to use coping skills. Sleep disturbance remains significant. Risk assessed as low due to denial of SI/HI and presence of protective factors.

P (Plan): Continue weekly trauma-focused therapy. Provide psychoeducation on trauma and self-blame. Assign daily grounding practice and sleep hygiene steps. Begin cognitive restructuring of guilt statements next session. Encourage client to identify 2 safe supports to contact during high distress. Monitor nightmares and consider referral for medication consult if sleep does not improve.

Car Accident Trauma

Acute Stress After Motor Vehicle Accident

S (Subjective): Client reports ongoing fear of driving after a car accident 3 weeks ago. Client states they feel panic when riding in a car and avoid highways. Client reports flashbacks when hearing loud brakes. Client states they feel “on edge” and startle easily. Client reports poor sleep and waking up sweating. Client denies suicidal thoughts.

O (Objective): Client appeared restless and frequently shifted in chair. Breathing increased while discussing accident details. Client’s voice became shaky. Client maintained good orientation and was able to follow the session. No cognitive impairment observed. Client responded well to paced breathing and grounding.

A (Assessment): Symptoms consistent with acute stress reaction. Client shows high anxiety and avoidance behaviors. Client demonstrates good motivation for treatment. Risk assessed as low.

P (Plan): Continue therapy weekly for stabilization. Teach paced breathing and grounding for panic. Begin gradual exposure planning for driving in small steps. Encourage client to track triggers and rate anxiety levels. Provide education on trauma responses and normal recovery. Follow up next session on sleep and panic frequency.

Childhood Trauma

Complex Trauma with Emotional Dysregulation

S (Subjective): Client reports feeling overwhelmed and emotionally “out of control” this week. Client states they had strong anger and sadness after conflict with partner. Client reports childhood trauma memories were triggered by being yelled at. Client states they feel unsafe when others raise their voice. Client reports episodes of dissociation where time feels “missing.” Client denies suicidal ideation but reports passive thoughts like “I don’t want to feel this anymore.”

O (Objective): Client presented with flat affect at start of session and became tearful later. Client paused often and appeared to dissociate briefly. Therapist used grounding and client re-oriented within 1 minute. Client’s speech was soft and slowed during emotional topics. Client was oriented x4. No current intent or plan for self-harm observed.

A (Assessment): Client continues to show symptoms consistent with complex trauma, including emotional dysregulation, dissociation, and trigger-based responses. Client has increased awareness of triggers but limited coping skills under stress. Passive thoughts present but no intent or plan; risk assessed as low to moderate due to emotional intensity.

P (Plan): Continue weekly therapy with focus on stabilization and emotion regulation. Practice grounding and safe place imagery daily. Create a written coping plan for dissociation. Explore boundaries and communication strategies with partner. Reassess safety next session and encourage client to reach out to crisis resources if thoughts worsen.

Workplace Trauma

Trauma Symptoms After Workplace Assault

S (Subjective): Client reports fear and anxiety after being physically assaulted at work 2 months ago. Client states they have trouble returning to the workplace and experience panic before shifts. Client reports flashbacks when seeing people who look similar to the attacker. Client states they feel angry and unsafe in public. Client reports poor sleep and frequent irritability. Client denies suicidal ideation.

O (Objective): Client appeared guarded and hypervigilant. Client scanned the room often. Speech was clear and organized. Mood described as “angry and scared.” Affect was tense. Client demonstrated good insight and actively participated in session. No dissociation observed.

A (Assessment): Symptoms suggest PTSD, including hypervigilance, avoidance, sleep disturbance, and intrusive memories. Client remains highly distressed but engaged in treatment. Risk assessed as low.

P (Plan): Continue weekly trauma therapy. Teach grounding and safety cues for panic. Begin cognitive work on beliefs related to safety and control. Discuss workplace accommodations and support options. Encourage consistent sleep routine. Consider referral for psychiatric evaluation if sleep does not improve.

How to Document Trauma Without Writing Graphic Details?

Trauma notes should not become a detailed trauma story. In most cases, you only need a short description like “history of domestic violence” or “history of childhood physical abuse.” The purpose of the note is clinical care, not retelling. Writing graphic detail can increase legal risk and may not help treatment. A safer approach is to document the type of trauma, the symptom impact, and what interventions were used.

Trauma SOAP Note Best Phrases for Risk Documentation

Risk documentation is critical in trauma care. Many trauma clients experience suicidal thoughts at some point, especially when symptoms feel intense.

Here are safe, clear phrases you can use:

• “Client denies suicidal ideation, plan, or intent.”
• “Client reports passive suicidal thoughts without plan or intent.”
• “Protective factors include family support and future goals.”
• “Safety plan reviewed and crisis resources provided.”

Always document risk with clarity. Avoid vague statements like “client is fine.”

Trauma SOAP Note Grounding and Coping Skills to Document

Trauma therapy often includes grounding and coping skills. Documenting them shows the session had clinical value and structure.

Examples of skills you can document:

• 5-4-3-2-1 sensory grounding
• Box breathing
• Progressive muscle relaxation
• Safe place visualization
• Emotion labeling
• Distress tolerance skills
• Thought challenging
• Body scan and somatic grounding

You can also document the client’s response: “Client reported distress decreased from 8/10 to 4/10.”

Final Tips:

Writing trauma SOAP notes gets easier with practice. The key is to stay structured and use consistent clinical language in every session. Focus on the client’s symptoms, safety, and the treatment interventions you used. Avoid writing long or graphic details of the trauma story. Instead, document what matters clinically: triggers, emotional responses, coping skills, and progress toward goals. Track improvement in small steps, because trauma recovery often happens slowly and in phases. Always include a brief safety check when needed, especially if the client reports severe distress, self-harm thoughts, or unstable situations. In the Plan section, keep next steps realistic and trauma-informed, with a focus on stabilization, grounding, and support. Trauma work is deep and sensitive work. Your documentation should support the client’s healing while also protecting ethical standards, professional clarity, and safe continuity of care.

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