SOAP Notes: A Complete Guide with Template and Examples

SOAP notes are one of the most common ways clinicians organize patient documentation. They help turn a patient visit into a clear clinical note that is easy to read, review, and follow.

SOAP stands for:

• Subjective
• Objective
• Assessment
• Plan

A good SOAP note should explain what the patient reported, what the clinician observed, what the clinician thinks is happening, and what should happen next.

This guide explains what SOAP notes are, how to write them, what to include in each section, common mistakes to avoid, and how AI can help clinicians draft SOAP notes faster while keeping the clinician in control.

What are SOAP notes?

SOAP notes are structured clinical notes used to document patient encounters.

Each section has a specific purpose:

• Subjective: what the patient reports
• Objective: what the clinician observes, measures, or verifies
• Assessment: the clinician’s impression, diagnosis, or clinical reasoning
• Plan: the next steps for treatment, testing, follow-up, education, or referral

SOAP notes are used across many healthcare settings, including:

• Primary care
• Urgent care
• Behavioral health
• Physical therapy
• Occupational therapy
• Speech therapy
• Nursing
• Specialty clinics

The format is popular because it is simple, repeatable, and easy to scan. A clinician can quickly understand the patient’s concern, the findings, the assessment, and the plan.

Why SOAP notes matter

SOAP notes are not just paperwork. They support clear communication between clinicians and help create a reliable record of care.

A strong SOAP note can help with:

• Continuity of care
• Clinical reasoning
• Patient follow-up
• Team communication
• Medical documentation
• Visit summaries
• Care planning

A weak SOAP note can make it harder to understand what happened during the visit or what should happen next.

The four parts of a SOAP note

Subjective

The Subjective section includes what the patient reports.

This can include:

• Chief complaint
• History of present illness
• Symptoms
• Pain description
• Patient concerns
• Relevant medical history
• Medications
• Allergies
• Review of systems
• Social or family history when relevant

Helpful questions include:

• When did the problem start?
• Where is it located?
• How long has it been happening?
• What makes it better or worse?
• How severe is it?
• Has this happened before?
• Are there related symptoms?

The Subjective section is the patient’s story. It should capture what the patient says, feels, notices, or reports.

Objective

The Objective section includes what the clinician observes, measures, or verifies.

This can include:

• Vital signs
• Physical exam findings
• Mental status observations
• Lab results
• Imaging results
• Point-of-care tests
• Functional measurements
• Clinician observations

Objective information should be something another clinician could observe or verify.

Examples:

• Temperature: 100.8°F
• Heart rate: 98 bpm
• Lungs clear to auscultation
• Patient appears anxious but cooperative
• Rapid strep test negative

A common mistake is putting patient-reported symptoms in Objective. If the patient says, “My chest feels tight,” that belongs in Subjective. If the clinician hears wheezing on exam, that belongs in Objective.

Assessment

The Assessment section explains what the clinician thinks is happening.

This can include:

• Primary diagnosis
• Differential diagnosis
• Problem list
• Clinical impression
• Progress since last visit
• Risk level
• Clinical reasoning

A weak assessment might say:

Cough.

A stronger assessment might say:

Acute cough, likely viral upper respiratory infection given short duration, mild fever, no shortness of breath, and clear lung exam.

The Assessment should connect the Subjective and Objective sections to the clinician’s reasoning.

Plan

The Plan section explains what happens next.

This can include:

• Medications
• Labs or imaging
• Procedures
• Referrals
• Patient education
• Safety instructions
• Follow-up timing
• Return precautions
• Therapy goals
• Monitoring plan

A strong Plan should be clear and actionable.

Instead of:

Follow up if worse.

A better Plan might say:

Increase fluids and rest. Use symptom relief as appropriate. Return if symptoms worsen, shortness of breath develops, fever persists, or new chest pain occurs. Follow up if symptoms are not improving.

SOAP note template

Use this simple SOAP note template as a starting point.

Patient / Encounter Information

• Patient initials or ID:
• Date:
• Provider:
• Visit type:
• Reason for visit:

Subjective

• Chief complaint:
• History of present illness:
• Relevant past medical history:
• Medications:
• Allergies:
• Relevant review of systems:
• Patient goals or concerns:

Objective

• Vital signs:
• General appearance:
• Physical exam findings:
• Mental status or functional observations:
• Labs:
• Imaging:
• Other results:

Assessment

• Primary problem:
• Diagnosis or clinical impression:
• Differential diagnosis:
• Clinical reasoning:
• Progress since last visit:
• Risk level or concerns:

Plan

• Tests or labs ordered:
• Medications or treatment:
• Patient education:
• Referrals:
• Follow-up:
• Return precautions:
• Goals:
• Next steps:

This template is only a starting point. The right structure may vary by specialty, setting, payer requirements, and clinical workflow.

SOAP note example: primary care

Fictional example only. This is not a real patient and contains no real protected health information. It is for educational purposes only and should not be used as medical advice.

Patient / Encounter Information

• Patient: Fictional adult patient
• Visit type: Primary care visit
• Reason for visit: Cough and sore throat

Subjective

Patient reports:

• Three-day history of cough and sore throat
• Mild fatigue
• Dry cough, worse at night
• Low-grade fever at home
• No chest pain
• No shortness of breath
• No wheezing
• No history of asthma or chronic lung disease reported
• No medication allergies reported

Objective

Clinician notes:

• Temperature mildly elevated
• Oxygen saturation normal on room air
• Patient appears tired but in no acute distress
• Throat mildly red without exudate
• Lungs clear bilaterally
• No wheezing or crackles
• Heart rate regular

Assessment

Acute cough and sore throat, most consistent with viral upper respiratory infection. Bacterial pharyngitis is less likely based on the absence of tonsillar exudate and significant lymph node findings. Pneumonia is less likely based on normal oxygen saturation and clear lung exam.

Plan

Recommend supportive care with fluids, rest, and symptom relief as appropriate.

Discussed warning signs:

• Shortness of breath
• Chest pain
• Persistent high fever
• Worsening symptoms
• Symptoms lasting longer than expected

Patient advised to follow up if symptoms do not improve or if new concerning symptoms develop.

SOAP note example: behavioral health

Fictional example only. This is not a real patient and contains no real protected health information. It is for educational purposes only and should not be used as medical advice.

Patient / Encounter Information

• Patient: Fictional adult client
• Visit type: Behavioral health session
• Reason for visit: Stress and sleep difficulty

Subjective

Client reports:

• Increased work-related stress over the past two weeks
• Difficulty falling asleep
• Frequent worry at night
• Lower focus during the day
• Breathing exercises help “a little”
• No current thoughts of self-harm reported

Objective

Clinician notes:

• Client arrived on time
• Cooperative throughout session
• Affect appeared mildly anxious
• Speech normal in rate and tone
• Thought process organized
• Client oriented and engaged
• No acute safety concerns observed during session

Assessment

Client presents with increased stress and sleep difficulty related to work demands. Symptoms appear to be affecting sleep and concentration. Client demonstrates insight and willingness to practice coping strategies. Continued monitoring of mood, anxiety symptoms, sleep patterns, and safety is appropriate.

Plan

• Reviewed sleep hygiene strategies
• Practiced a brief grounding exercise
• Client will track sleep patterns and stress triggers before next session
• Continue supportive therapy and coping-skills work
• Follow up at next scheduled session
• Client reminded to seek immediate support if safety concerns arise

Common SOAP note mistakes

Mixing Subjective and Objective information

Subjective is what the patient reports. Objective is what the clinician observes or measures.

Example:

• “Patient reports dizziness” = Subjective
• “Blood pressure 90/60” = Objective

Writing a vague Assessment

The Assessment should explain the clinician’s impression, not just repeat the chief complaint.

Weak:

Cough.

Better:

Acute cough, likely viral upper respiratory infection based on short duration, mild fever, and clear lung exam.

Writing a Plan that is too general

The Plan should be specific enough that another clinician can understand the next steps.

Avoid vague plans like:

• Continue medication
• Follow up later
• Monitor symptoms

Instead, clarify what should happen, when, and what warning signs matter.

Copying forward old notes without updating them

Copy-forward documentation can save time, but it can also create inaccurate records if old details remain in the note. Each SOAP note should reflect the actual visit.

Including too much unnecessary detail

SOAP notes should be complete, but they should not be overloaded. Too much unrelated information makes the note harder to read.

Forgetting follow-up and patient education

The Plan should often include what the patient was told, what to watch for, and when to return.

SOAP notes vs. DAP, BIRP, APSO, and PIE notes

SOAP is not the only documentation format. Different settings use different note styles.

SOAP

SOAP stands for Subjective, Objective, Assessment, and Plan. It is widely used across medical, therapy, rehabilitation, and specialty care settings.

DAP

DAP stands for Data, Assessment, and Plan. It is often used in behavioral health. The Data section may include both subjective and objective information.

BIRP

BIRP stands for Behavior, Intervention, Response, and Plan. It is often used in behavioral health and case management.

APSO

APSO is a variation of SOAP that puts Assessment and Plan first. This can make notes faster to scan because the clinical impression and next steps appear at the top.

PIE

PIE stands for Problem, Intervention, and Evaluation. It is often used in nursing documentation.

Which format is best?

There is no single best format for every setting. SOAP is one of the most widely used because it is clear, flexible, and easy to teach. The right format depends on specialty, documentation requirements, workflow, and team preference.

SOAP notes by specialty

SOAP notes can be adapted to many specialties.

Primary care

Often focuses on symptoms, chronic conditions, medication management, preventive care, and follow-up.

Behavioral health

May include reported mood, observed affect, therapeutic interventions, risk assessment, coping skills, and treatment goals.

Physical therapy and occupational therapy

Often focuses on function, pain level, range of motion, strength, activity tolerance, interventions, response to treatment, and goals.

Speech therapy

May include communication goals, swallowing concerns, session tasks, patient response, cueing level, and progress.

Nursing

May include patient status, symptoms, interventions, education, response, and escalation when needed.

Specialty care

May include condition-specific history, exam findings, test interpretation, treatment decisions, and follow-up planning.

SOAP notes and AI documentation

AI can help clinicians draft SOAP notes faster.

An AI SOAP note generator or AI medical scribe can listen to a patient encounter and organize the conversation into a structured note. The clinician then reviews, edits, and signs the final documentation.

AI can help with:

• Organizing the conversation into SOAP format
• Reducing repetitive typing
• Creating a first draft faster
• Supporting consistent note structure
• Helping with follow-up summaries
• Reducing after-hours documentation

However, AI-generated SOAP notes still need human review. The clinician remains responsible for the final note. AI should support documentation, not replace medical judgment.

If you want to understand how AI medical scribes work, read our guide to choosing the best AI medical scribe or see how DocuMed AI works.

What to check before using AI for SOAP notes

Before using AI for SOAP notes in a real clinical setting, ask:

• Is the tool designed for healthcare?
• Does it support HIPAA-compliant workflows?
• Will the vendor sign a BAA?
• Does it store audio?
• Does it train models on patient data?
• Can the clinician edit the note before signing?
• Does it support your specialty?
• Does it fit your EHR workflow?
• Is pricing clear?
• Can you test it safely before using it widely?

AI can reduce documentation burden, but it should be implemented carefully.

How to write better SOAP notes

To improve SOAP notes, make each section do its job:

• Subjective: what the patient says
• Objective: what you observe or measure
• Assessment: what you think is happening
• Plan: what happens next

Then focus on clarity.

A good SOAP note should answer:

• Why did the patient come in?
• What did the clinician find?
• What does the clinician think?
• What is the plan?
• What should happen next?

Frequently asked questions

What is a SOAP note?

A SOAP note is a structured clinical note organized into four sections: Subjective, Objective, Assessment, and Plan.

What are the four parts of a SOAP note?

The four parts are Subjective, Objective, Assessment, and Plan.

What is the difference between Subjective and Objective in SOAP notes?

Subjective information comes from the patient’s report. Objective information is observed, measured, or verified by the clinician.

What should the Assessment include?

The Assessment should include the clinician’s diagnosis, impression, problem list, differential diagnosis, or clinical reasoning.

How long should a SOAP note be?

A SOAP note should be long enough to clearly document the encounter, but not longer than needed. Many SOAP notes are brief, while complex visits may require more detail.

What is the difference between SOAP, DAP, and BIRP notes?

SOAP uses Subjective, Objective, Assessment, and Plan. DAP uses Data, Assessment, and Plan. BIRP uses Behavior, Intervention, Response, and Plan.

Can AI write SOAP notes?

AI can help draft SOAP notes from a clinical conversation, but the clinician should review, edit, and approve the final note.

Are AI-generated SOAP notes accurate?

AI-generated SOAP notes can be useful first drafts, but they are not perfect. Accuracy depends on audio quality, visit complexity, specialty language, and clinician review.

Is there a free SOAP note template?

Yes. You can use the template in this guide as a starting point and adapt it to your specialty, setting, and documentation requirements.

Can SOAP notes be used for therapy?

Yes. SOAP notes can be used in behavioral health, although some therapists may prefer DAP or BIRP notes depending on their workflow and documentation requirements.

Final thoughts

SOAP notes remain popular because they are simple, structured, and useful across many healthcare settings. They help clinicians organize the patient story, objective findings, clinical reasoning, and plan in a way that supports communication and continuity of care.

The best SOAP notes are clear, specific, and clinically useful. They do not need to be long. They need to be accurate, organized, and easy to understand.

If documentation is taking too much time, DocuMed AI can help clinicians draft structured notes faster while keeping the clinician in control. See how DocuMed AI works or book a demo to learn how AI can support your SOAP note workflow.

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