What Is a SOAP Note? Format and Definition
A SOAP note is a structured method for documenting patient encounters, widely used by physicians, nurses, and therapists. The acronym stands for:
- Subjective: Patient-reported symptoms, medical history, and concerns.
- Objective: Measurable data like vital signs, physical exam findings, and test results.
- Assessment: The clinician’s professional diagnosis or differential diagnoses.
- Plan: Treatment plan, including interventions, referrals, and follow-up steps.
This subjective objective assessment plan format ensures consistency, supports billing, and enhances interdisciplinary collaboration. With AI tools in healthcare, SOAP notes are now faster to create, more accurate, and fully compliant with HIPAA and EHR standards.
- Standardization: Ensures consistent documentation across specialties.
- Efficiency: Reduces errors and time spent on manual charting.
- Compliance: Meets healthcare documentation standards 2025 and HIPAA requirements.
- Integration: EHR-compatible SOAP notes streamline workflows with systems like Epic and Cerner.
Below are 18 SOAP note examples and templates for 2025, covering various specialties and use cases. Each template is designed to be EHR-compatible, customizable, and optimized for AI-generated SOAP notes. Download them for free to streamline your physician documentation.
Use Case: Primary care physicians documenting routine visits.
Example:
Subjective: 45-year-old male reports fatigue and occasional chest discomfort for 2 weeks. Denies shortness of breath or palpitations.
Objective: BP 130/80, HR 72, Temp 98.6°F. EKG normal, no murmurs.
Assessment: Possible stress-related fatigue; rule out cardiac etiology.
Plan: Order stress test, recommend lifestyle changes, follow-up in 2 weeks.
Use Case: Mental health providers documenting therapy sessions.
Example:
Subjective: 32-year-old female reports increased anxiety and poor sleep. PHQ-9 score: 16 (moderate depression).
Objective: Flat affect, slow speech, no suicidal ideation. Vital signs stable.
Assessment: Major depressive disorder, moderate.
Plan: Start sertraline 50 mg daily, refer to CBT, follow-up in 1 month.
Use Case: Physical therapists documenting mobility assessments.
Example:
Subjective: 60-year-old male reports right knee pain, worse with stairs. No recent trauma.
Objective: ROM limited to 90° flexion, strength 4/5, positive McMurray’s test.
Assessment: Suspected meniscal tear.
Plan: Initiate PT exercises, refer to orthopedist, MRI ordered.
4. Nursing SOAP Note Template: For RNs Documenting Inpatient Care
Use Case: Registered nurses documenting post-surgical or inpatient care.
Example:
Subjective: 72-year-old female, post-hip replacement, reports moderate pain (5/10) in right hip and difficulty ambulating. States, “It hurts when I try to stand.”
Objective: BP 128/82, HR 78, RR 16, Temp 98.7°F, SpO2 98%. Right hip incision clean, no swelling. Limited ROM, pain with movement.
Assessment: Postoperative pain, expected recovery phase, risk for immobility-related complications.
Plan: Administer acetaminophen 650 mg every 6 hours PRN. Assist with PT exercises, encourage incentive spirometry, monitor vitals q4h, educate on fall precautions.
5. Pediatric SOAP Note Template: For Pediatricians Tracking Child Development
Use Case: Pediatricians documenting well-child visits or developmental assessments.
Example:
Subjective: 3-year-old male, mother reports delayed speech and frequent ear infections. “He only says a few words.”
Objective: Wt 32 lbs (50th percentile), Ht 37 in (60th percentile), Temp 98.4°F. Tympanic membranes erythematous bilaterally. Speech: 10–15 vocabulary words, below age norm.
Assessment: Speech delay, recurrent otitis media.
Plan: Refer to speech therapy, prescribe amoxicillin 400 mg BID x10 days, follow-up in 2 weeks, developmental screening.
Use Case: Cardiologists documenting cardiac evaluations.
Example:
Subjective: 60-year-old male reports chest pressure and dyspnea on exertion for 1 month. Denies syncope.
Objective: BP 140/90, HR 92, RR 18, SpO2 95%. EKG: ST depression in V5–V6. Heart: S1, S2 normal, no murmurs.
Assessment: Stable angina, uncontrolled hypertension.
Plan: Order stress test, start metoprolol 25 mg daily, aspirin 81 mg daily, follow-up in 1 week.
Use Case: Orthopedists documenting joint or bone injuries.
Example:
Subjective: 45-year-old female reports left shoulder pain for 3 weeks, worse with overhead activities.
Objective: Left shoulder: ROM limited to 90° abduction, positive impingement sign. Strength 4/5. X-ray: No fracture.
Assessment: Rotator cuff tendinitis.
Plan: Prescribe ibuprofen 600 mg TID, refer to PT, cortisone injection if no improvement, follow-up in 3 weeks.
Use Case: Oncologists documenting cancer care.
Example:
Subjective: 55-year-old female with breast cancer reports fatigue and mild nausea post-chemotherapy.
Objective: BP 118/76, HR 80, Wt 140 lbs (down 5 lbs). Labs: WBC 3.8, Hgb 11.2. No lymphadenopathy.
Assessment: Stage II breast cancer, tolerating chemotherapy with mild side effects.
Plan: Continue cycle 3 of chemotherapy, prescribe ondansetron 8 mg PRN, follow-up post-cycle 4.
Use Case: Neurologists documenting neurological conditions.
Example:
Subjective: 70-year-old male reports memory lapses and difficulty concentrating for 6 months.
Objective: Mini-Mental State Exam: 24/30. Cranial nerves intact, no motor deficits. MRI: Mild cortical atrophy.
Assessment: Mild cognitive impairment, possible early Alzheimer’s.
Plan: Start donepezil 5 mg daily, refer to neuropsychology, follow-up in 3 months.
Use Case: Dermatologists documenting skin disorders.
Example:
Subjective: 30-year-old male reports itchy rash on arms for 2 weeks.
Objective: Bilateral forearms: Erythematous papules, excoriations. No systemic symptoms.
Assessment: Contact dermatitis, likely allergic.
Plan: Prescribe hydrocortisone 1% cream BID, antihistamine PRN, avoid irritants, follow-up in 2 weeks.
Use Case: Gastroenterologists documenting digestive disorders.
Example:
Subjective: 50-year-old female reports epigastric pain and bloating for 1 month.
Objective: Abdomen: Soft, tender epigastrium, no rebound. Labs: H. pylori positive.
Assessment: Gastritis, H. pylori infection.
Plan: Start triple therapy (amoxicillin, clarithromycin, PPI) x14 days, follow-up in 4 weeks.
Use Case: OB/GYNs documenting prenatal or gynecological care.
Example:
Subjective: 28-year-old G2P1 at 28 weeks gestation reports mild contractions.
Objective: Fundal height 28 cm, fetal HR 140 bpm. Cervix: Closed, no effacement.
Assessment: Braxton Hicks contractions, normal pregnancy.
Plan: Hydration, rest, educate on preterm labor signs, follow-up in 2 weeks.
Use Case: Geriatricians documenting elderly care.
Example:
Subjective: 82-year-old female reports fatigue and recent falls.
Objective: BP 130/80, HR 76. Gait unsteady, uses cane. Labs: Vitamin D 20 ng/mL.
Assessment: Frailty, vitamin D deficiency, fall risk.
Plan: Start vitamin D 1000 IU daily, refer to PT for balance training, follow-up in 1 month.
14. Emergency Medicine SOAP Note Template: For Urgent Care Settings
Use Case: ER physicians documenting acute conditions.
Example:
Subjective: 35-year-old male reports sudden chest pain and shortness of breath.
Objective: BP 150/90, HR 110, SpO2 92%. EKG: No ST elevation. Troponin pending.
Assessment: Acute chest pain, rule out ACS vs. PE.
Plan: Administer aspirin 325 mg, order CT angiogram, admit to telemetry.
Use Case: Occupational therapists documenting rehabilitation.
Example:
Subjective: 50-year-old male post-stroke reports difficulty with ADLs.
Objective: Right upper extremity: Strength 3/5, limited fine motor skills.
Assessment: Impaired functional mobility due to CVA.
Plan: Initiate ADL training, provide adaptive equipment, OT 3x/week, follow-up in 2 weeks.
Use Case: Acupuncturists documenting treatments.
Example:
Subjective: 35-year-old female reports chronic migraines for 6 months.
Objective: Tense neck muscles, pulse weak. No contraindications.
Assessment: Qi stagnation, tension headaches.
Plan: Acupuncture at LI4, GB20 points, recommend stress reduction, follow-up in 1 week.
Use Case: Pharmacists documenting medication reviews.
Example:
Subjective: 65-year-old male reports adherence issues with polypharmacy.
Objective: Current meds: Metformin, lisinopril, atorvastatin. A1C 7.8%.
Assessment: Suboptimal diabetes control, medication non-adherence.
Plan: Simplify regimen, provide pill organizer, educate on adherence, follow-up in 2 weeks.
Use Case: Podiatrists documenting foot conditions.
Example:
Subjective: 50-year-old male reports heel pain for 3 months, worse in AM.
Objective: Right heel: Tender on palpation, no swelling. X-ray: No spur.
Assessment: Plantar fasciitis.
Plan: Prescribe orthotics, stretching exercises, ibuprofen 400 mg TID PRN, follow-up in 4 weeks.
Writing a SOAP note can be daunting, especially for students or new clinicians. Follow this how to write a SOAP note step by step guide to create accurate SOAP note documentation.
- Subjective: Record the patient’s chief complaint, history of present illness, and relevant medical history. Use direct quotes when possible (e.g., “I feel tired all the time”).
- Objective: Document measurable data like vital signs, lab results, and physical exam findings. Be precise (e.g., “BP 128/76, HR 92”).
- Assessment: Analyze subjective and objective data to form a diagnosis or differential diagnoses. Include clinical reasoning (e.g., “Suspected hypertension; rule out thyroid dysfunction”).
- Plan: Outline the treatment plan, including medications, referrals, and follow-up instructions. Be specific (e.g., “Prescribe lisinopril 10 mg daily, follow-up in 2 weeks”).
Pro Tip: Use AI tools like S10.AI to automate this process. S10.AI’s AI medical scribe listens to patient encounters, transcribes data, and generates SOAP notes for physicians in seconds, compatible with EHRs like Epic, Cerner, and AthenaHealth.
AI in healthcare is transforming physician documentation by reducing administrative burden and improving efficiency. Here’s how AI medical scribes like S10.AI help:
- Time Savings: Clinicians save 6–10 minutes per patient encounter, cutting documentation time by up to 50%.
- Accuracy: AI-generated SOAP notes reduce errors by leveraging advanced speech recognition and NLP.
- EHR Integration: Seamlessly integrates with Epic, Cerner, AthenaHealth, eClinicalWorks, and more for EHR-compatible SOAP notes.
- Burnout Reduction: By automating charting, AI scribes reduce “pajama time” by 30%, improving clinician well-being.
- Customization: Offers SOAP note templates tailored to specialties like mental health, physical therapy, and nursing.
Case Study: Dr. Julie Johnson, a family medicine physician, implemented S10.AI’s AI medical scribe and reported: “My stress level dropped significantly. I can focus on my patients instead of typing.” This allowed her to see 2 additional patients daily, boosting practice revenue by 15%.
Mental health providers benefit from AI-generated SOAP notes that capture nuanced patient interactions.
Example:
Subjective: Patient reports worsening anxiety, trouble sleeping for 3 weeks.
Objective: PHQ-9 score 18, GAD-7 score 15, vital signs stable.
Assessment: Generalized anxiety disorder, moderate depression.
Plan: Increase sertraline to 100 mg, refer to psychiatrist, mindfulness exercises. Download: Mental Health SOAP Note Template
Physical therapists can use SOAP note templates to document functional progress.
Example:
Subjective: Patient reports lower back pain, difficulty bending.
Objective: Lumbar ROM 50% reduced, positive straight leg raise.
Assessment: Lumbar strain, possible disc involvement.
Plan: Core strengthening exercises, manual therapy, follow-up in 1 week. Download: Physical Therapy SOAP Note Template
Notes for Nursing Nurses rely on SOAP note format for student nurses to document inpatient care.
Example:
Subjective: Patient reports nausea and dizziness post-surgery.
Objective: BP 110/70, HR 88, Temp 99.2°F, incision clean.
Assessment: Postoperative nausea, stable recovery.
Plan: Administer ondansetron 4 mg IV, monitor vitals q4h. Download: Nursing SOAP Note Template
Investing in AI tools in healthcare like S10.AI offers measurable ROI:
- Productivity Boost: Clinics report a 40% reduction in documentation time.
- Cost Savings: AI scribes are more cost-effective than human scribes, reducing overhead.
- Improved Patient Care: Clinicians spend more time with patients, enhancing satisfaction.
- Compliance: HIPAA-compliant AI medical scribes ensure data security.
Choosing the Best AI Medical Scribe for Your Practice
When selecting an AI medical scribe, consider:
- EHR Integration: Compatibility with Epic, Cerner, AthenaHealth, and eClinicalWorks.
- Customization: Ability to create SOAP note templates for specific specialties.
- Accuracy: Advanced NLP and speech recognition for error-free notes.
- Cost: Subscription-based models with clear ROI, like S10.AI’s scalable pricing.
S10.AI Advantage: S10.AI supports all specialties, from primary care to acupuncture, and integrates with any EHR, ensuring best AI performance for physician documentation improvement.
A SOAP note example includes subjective patient complaints, objective clinical findings, a professional assessment, and a detailed treatment plan. See the examples above for specialty-specific templates.
Follow the subjective objective assessment plan format:
- Document patient-reported symptoms (Subjective).
- Record measurable data like vitals (Objective).
- Analyze data for a diagnosis (Assessment).
- Outline treatment and follow-up (Plan).
Download SOAP note templates for free from S10.AI, including specialties like mental health, nursing, and physical therapy.
AI medical scribes like S10.AI use speech recognition and NLP to transcribe patient encounters, categorize data into SOAP note format, and integrate with EHRs like Epic and Cerner. Clinicians review and sign off on notes, saving hours daily.
In 2025, SOAP note examples and templates are essential tools for clinicians aiming to streamline physician documentation and combat burnout. By leveraging AI in healthcare, particularly AI medical scribes like S10.AI, providers can save time, reduce errors, and focus on patient care. S10.AI’s best AI solution integrates with any EHR, supports all specialties, and offers customizable SOAP note templates to meet healthcare documentation standards 2025.
FAQs
1) How does the SOAP note format differ across various healthcare professions (e.g., psychiatry, pediatrics, obstetrics, therapy, counseling, dermatology, speech therapy, nursing, urology, occupational therapy)?
What are some practical SOAP note examples for mental health professionals in 2025?
SOAP notes are essential for mental health professionals to document patient interactions effectively. In 2025, examples include detailed notes on patient progress, treatment plans, and therapy outcomes. These notes help in maintaining a structured record, ensuring continuity of care, and facilitating communication among healthcare providers. Exploring various SOAP note templates can enhance your documentation skills and improve patient care.
How can SOAP note templates improve efficiency in clinical practice?
SOAP note templates streamline the documentation process by providing a structured format for recording patient information. This efficiency allows clinicians to focus more on patient care rather than paperwork. By adopting these templates, healthcare providers can ensure consistency, reduce errors, and enhance communication within the care team. Utilizing SOAP note templates can significantly improve the quality and efficiency of clinical practice.
Why is it important to use updated SOAP note templates in 2025?
Using updated SOAP note templates in 2025 is crucial for maintaining compliance with current healthcare standards and regulations. These templates incorporate the latest best practices and technological advancements, ensuring that documentation is accurate and comprehensive. Staying current with updated templates can enhance patient care, improve clinical outcomes, and ensure that your practice remains competitive and efficient.
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