SOAP note
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Document patient encounters, interventions, and plans in the SOAP format: subjective data, objective data, assessment, and plan.
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Captures subjective (patient-related symptoms and histories), objective (observations, measurements, and test results discussed), assessment (diagnosis and evaluation), and plan (treatment and follow-up).
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Encompasses diverse clinical domains and more detailed rationale for care. Also emphasizes individualized factors, clarifies targeted objectives, and supports richer understanding and more responsive, tailored interventions.
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Aligns with Headway's note structure, capturing clinical summaries, diagnostic support statements, medical necessity, and progress toward treatment objectives.
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How it works
SOAP notes are a progress note template with sections corresponding to the SOAP acronym: subjective, objective, assessment, plan. If you’d like you learn more about SOAP notes, you can read our SOAP note guide.
AI-generated SOAP notes use artificial intelligence to interpret relevant information from a therapy session and produce a SOAP note for the session.
Upheal AI notes are HIPAA compliant. However, not all AI notes are HIPAA compliant. Ensure the AI tools you use to create clinical notes are HIPAA compliant by reviewing the privacy section of their website.
You can learn more about Upheal’s compliance on our HIPAA compliance page.
You can generate unlimited clinical notes using Upheal AI for free!
If you’d like advanced features like different note types, treatment plans, and client summaries, you can sign up to one of our paid plans.
To find the right plan for your practice, visit our pricing page.
Absolutely. You can capture online sessions without even leaving your EHR. Our extension works with any telehealth or video-calling platform. You can also capture audio during in-person sessions or choose to upload audio recordings manually.
Either way, it’s easy to copy-paste the note content to your EHR.
Administrative tasks like note-taking are time-consuming. They are also usually done during sessions, or in your personal time. This contributes to burnout, limits the number of clients you can see, and ultimately impacts patient care.
AI scribes like Upheal, are up to 90% faster than manually writing clinical notes, giving you back 6+ hours a week and allowing you to stay present during consultations.
This is time you can use to, take on new clients, develop your skills, or spend with family.
No, we are not. Our goal is to support the therapist in the work that they do and provide better life balance with AI-powered automation.
We do a limited amount of data training for specific scenarios like medication and name recognition, prompt evaluation, or to test the accuracy of our notes.
Clients have the option to participate or decline in the sharing of their data for improvements to the Upheal app.
Set your hours once and offer in-person and telehealth from one link. Clients book, forms go out, reminders follow.
Give clients a self-serve space, so you can get back to what you trained for.
One click to join HIPAA-compliant virtual sessions. No downloads or installation needed.
Invoices go out once the session ends, or the saved card is charged automatically. Superbills pull codes from your signed note.
AI-powered migration imports your clients, notes, and data from SimplePractice, TherapyNotes, Sessions Health, or any other EHR. Drop in your export and the AI Assistant guides you through it step by step. Most therapists are running on Upheal before their next session.
Prefer a walkthrough? Our support team is on hand for your first import, and self-serve migration is free for everyone.
Upheal streamlines clinical documentation so you can save time on note-taking and be more attentive during sessions.
100% HIPAA compliant
Unlimited AI notes
Free plan
