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SOAP Note Template and Examples for Clinicians

The ScribeMD Team ·

It's 4:45 on a Thursday. Your last patient left twenty minutes ago and you still have nine notes open. You know what happened in each visit. The hard part is getting it into a structure the next reader can scan in thirty seconds.

The SOAP note is that structure. Below is a plain template you can copy, three worked SOAP note examples from different settings, and the habits that keep each section short and useful.

What a SOAP note is

SOAP stands for Subjective, Objective, Assessment, Plan. It's the most common format for progress notes in primary care, specialty clinics, therapy, physical therapy, and nursing. Each section answers one question:

  • Subjective: what the patient tells you.
  • Objective: what you measure or observe.
  • Assessment: what you think is going on.
  • Plan: what happens next.

The order mirrors clinical reasoning: gather the story, check it against findings, make a judgment, act on it. A reader who only has time for the assessment and plan should still understand the visit.

SOAP note template

Copy this into your EHR as a starting point and delete what doesn't apply to your specialty.

S: Subjective

  • Chief complaint: the reason for the visit, in the patient's words when possible.
  • History of present illness: onset, location, duration, character, aggravating and relieving factors, timing, severity, and what they've tried.
  • Pertinent review of systems: relevant positives and negatives.
  • Relevant history: past medical, surgical, family, and social history that matters for today's problem.
  • Medications and allergies: current list, changes since the last visit, adherence.

O: Objective

  • Vital signs: BP, HR, RR, temperature, SpO2, weight or BMI as relevant.
  • Physical exam: focused on the systems that matter for the complaint.
  • Results: labs, imaging, screening scores, or point-of-care tests reviewed today.

A: Assessment

  • Diagnosis or problem list: one line per problem, most important first.
  • Reasoning: a sentence or two on why, plus the differential you considered when it isn't obvious.
  • Status: new, improving, stable, or worsening for ongoing problems.

P: Plan

  • Diagnostics: tests ordered and why.
  • Treatment: medications started, stopped, or changed, and non-drug measures.
  • Referrals: who, and what question you want answered.
  • Education: what you explained and what the patient agreed to.
  • Follow-up: when, and the return precautions you gave.

SOAP note example 1: acute visit in primary care

  • S: 42-year-old with low back pain for 5 days after moving furniture. Pain is in the lower back, aching, worse with bending, better lying down. No radiation below the knee, no numbness or weakness, no bowel or bladder changes, no fever, no history of cancer. Has tried heat and an over-the-counter pain reliever with partial relief. Works at a desk.
  • O: Afebrile, vitals within normal limits. Paraspinal tenderness at L4 to L5 bilaterally, no midline tenderness. Range of motion limited by pain in flexion. Straight leg raise negative bilaterally. Strength, sensation, and reflexes in the lower extremities normal and symmetric.
  • A: Acute mechanical low back pain, likely muscular strain. No red-flag features on history or exam. Imaging not indicated at this point.
  • P: Stay active as tolerated and avoid bed rest. Continue heat. Reviewed over-the-counter analgesic options and label directions. Gentle stretching handout given. Return or call sooner for leg weakness, numbness, bowel or bladder changes, fever, or pain that keeps getting worse. Follow up in 4 weeks if not improving; would consider physical therapy then.

SOAP note example 2: chronic disease follow-up

  • S: 58-year-old here for hypertension follow-up. Taking current medication daily, misses a dose about once a week. Home readings mostly in the 130s over 80s. No headaches, chest pain, shortness of breath, or swelling. Has cut back on salt and walks three times a week.
  • O: BP 136/84 seated, repeat 134/82. HR 72, regular. BMI unchanged from last visit. Heart regular rate and rhythm, no murmur. Lungs clear. No peripheral edema. Basic metabolic panel from last week reviewed: within normal limits.
  • A: Hypertension, improved since last visit and close to goal. Adherence mostly good, with occasional missed doses.
  • P: Continue current medication at the same dose. Discussed a pill organizer and phone reminder for missed doses. Continue home monitoring and bring the log next time. Keep up diet and activity changes. Recheck in 3 months.

SOAP note example 3: therapy session

  • S: Client reports "a better week." Had two panic-like episodes at work, down from five the week before. Used the breathing exercise both times and said it "took the edge off." Still avoiding the team meeting. Sleep about six hours, falling asleep faster. Denies thoughts of self-harm.
  • O: On time, casually dressed, good eye contact. Speech normal in rate and volume. Mood described as "okay." Affect mildly anxious, brightened when discussing progress. Thought process linear. GAD-7 score lower than at intake.
  • A: Generalized anxiety with panic symptoms, improving. Engaged in treatment and using skills between sessions. Avoidance of work meetings remains the main barrier.
  • P: Continue weekly CBT. Built a graded exposure plan: attend the first 10 minutes of next week's team meeting. Continue the breathing practice daily. Reviewed the crisis plan. Next session in one week.

Behavioral health clinicians who prefer a different structure can compare formats in our guides to DAP notes and BIRP notes.

Habits that make SOAP notes better

Keep subjective and objective separate

"Patient is anxious" belongs in the assessment, or in objective if you describe what you saw. "Patient says she feels anxious" is subjective. Mixing them is the most common SOAP mistake and it makes the note harder to defend.

Write pertinent negatives

In example 1, "no bowel or bladder changes" and "no history of cancer" do real work. They show you screened for the serious causes. A long list of irrelevant negatives does the opposite and buries what matters.

Make the assessment say something

A diagnosis alone is a label. Add the status and one line of reasoning. "Hypertension, improved and close to goal" tells the next clinician far more than "HTN."

Make the plan checkable

Every plan item should be something someone could verify later: a test ordered, a change made, a date to return, a warning given. "Monitor" without a when or a what isn't a plan.

Don't copy forward without reading

Templates and copy-forward save time until last month's exam ends up in today's note. If you carry text forward, read every line and change what's different today.

Where an AI scribe fits

Most of the subjective section is already said out loud during the visit. An ambient AI scribe listens, with the patient's consent, and turns the conversation into a draft SOAP note. ScribeMD produces a draft in under 30 seconds and works with 35+ EHR integrations.

There are tradeoffs. The scribe only knows what was said, so exam findings you didn't narrate won't appear. You still review the draft, fix what's wrong, and sign it. Expect more edits in the first few weeks while you learn how to phrase things during the visit. The note stays yours. For a closer look at the workflow, read SOAP notes with an AI scribe.

If you'd like to see a SOAP draft generated from a real conversation, book a demo of ScribeMD.