SOAP Note Template
The SOAP note format is the gold standard for clinical documentation. Learn how to write effective SOAP notes or let AI generate them for you in seconds.
What is a SOAP Note?
A SOAP note is a structured method of documentation used by healthcare providers to organize patient encounter information. The acronym stands for Subjective, Objective, Assessment, and Plan—the four sections that make up every SOAP note.
This standardized format ensures consistent, comprehensive documentation that supports clinical decision-making, communication between providers, and billing compliance.
SOAP Note Format Explained
Subjective
What the patient tells you
What to include:
- Chief complaint
- History of present illness (HPI)
- Review of systems (ROS)
- Past medical/surgical history
- Medications
- Allergies
- Social/family history
Example:
CC: "I've had a sore throat for 3 days" HPI: 45-year-old male presents with 3 days of sore throat, associated with low-grade fever (100.2°F at home), mild odynophagia, and fatigue. Denies cough, rhinorrhea, or ear pain. No sick contacts. Tried ibuprofen with minimal relief. ROS: Positive for sore throat, fever, fatigue. Negative for cough, rhinorrhea, otalgia, rash.
Objective
What you observe and measure
What to include:
- Vital signs
- Physical examination findings
- Laboratory results
- Imaging findings
- Other test results
Example:
Vitals: T 100.4°F, BP 128/82, HR 88, RR 16, SpO2 98% RA General: Alert, mild distress, appears fatigued HEENT: TMs clear bilaterally. Pharynx erythematous with tonsillar exudates. No peritonsillar bulging. Neck: Tender anterior cervical lymphadenopathy bilaterally Lungs: Clear to auscultation Rapid strep: Positive
Assessment
Your clinical judgment
What to include:
- Diagnosis or differential diagnosis
- ICD-10 codes
- Clinical reasoning
- Problem list updates
Example:
1. Streptococcal pharyngitis (J02.0) - Positive rapid strep, classic presentation with tonsillar exudates and lymphadenopathy - Centor score 4 (fever, exudates, adenopathy, no cough)
Plan
Your treatment plan
What to include:
- Medications prescribed
- Procedures performed
- Patient education
- Follow-up instructions
- Referrals
Example:
1. Amoxicillin 500mg PO TID x 10 days 2. Ibuprofen 400mg PO Q6H PRN for pain/fever 3. Rest and increased fluids 4. May return to work/school after 24 hours of antibiotics if afebrile 5. Return if worsening symptoms, difficulty swallowing/breathing, or not improved in 48-72 hours
Skip the Manual Documentation
PatientNotes AI listens to your patient encounters and generates complete SOAP notes in seconds. No typing, no templates to fill out.
7-day free trial. No credit card required.
Tips for Writing Better SOAP Notes
Be Specific
Use precise descriptions. Instead of "patient has pain," write "sharp, 7/10 right lower quadrant pain."
Use Standardized Terminology
Stick to accepted medical terminology and abbreviations to ensure clarity across providers.
Document in Real-Time
The sooner you document, the more accurate your notes will be. Use AI scribes to capture details during the visit.
Include Clinical Reasoning
Your Assessment should explain why you reached your diagnosis, not just list it.