Yoga Therapy Session Note (SOAP, In-Person/Telehealth)

Client: [name]

DOB/MRN:

Date of Service:

Provider: [name, credentials]

Duration: [minutes]

Modality: [In-person / Telehealth audio-video / Telehealth audio-only]

Telehealth Safety

(Include only for telehealth sessions; omit entirely for in-person. All items must be explicitly documented, never inferred.)

Client Location: [city, state confirmed at session start]

Emergency Plan: [emergency contact name/phone confirmed; disconnect plan reviewed]

Environment Check: [space clear, camera adequate, props available, stop rules reviewed]

Consent: [telehealth consent obtained - verbal / written / electronic]

Connectivity: [none / describe issues affecting session]

Subjective

(1–2 short paragraphs. Use direct quotes sparingly for clinically significant statements. Omit content not reported by client.)

[Session focus and interval changes since last visit, including symptoms, function, stress/energy; home practice response noting adherence, benefit, and any adverse responses; current symptom anchors with numeric scales where relevant; short-term goals; any red flags reported and action taken]

Objective

Presentation: [affect, breathing pattern, movement quality, guarding]

Interventions: [practices delivered] (Document each component with plain-language description, dose (duration/reps/breath counts), props, and modifications. Include centering, breathwork, movement/asana, relaxation, and education as applicable. For in-person with hands-on assists, note consent obtained. For telehealth, note remote-instruction adaptations.)

Response: [tolerance, symptom change start-to-end, any adverse events] (Include client-reported and clinician-observed changes. Note telehealth observation limitations if applicable.)

Assessment

[Clinical synthesis] (2–4 sentences: response and trend versus prior session; progress toward goals [improving / plateauing / regressing]; rationale for progressions or modifications; scope considerations or referral needs. For telehealth, note how limitations affected conclusions if relevant.)

Plan

Next Session: [timing, focus, planned progressions or reassessments]

Home Practice: [assigned practices with dose (minutes/reps, frequency), props, and stop rules] (Include minimum-effective option for low-energy days when appropriate.)

Coordination: [communication with referring clinician or referral recommendations] (Omit if none.)

Signature: [provider signature, credentials, date/time signed]