SOAP Note Template (With Example)

Overview of the SOAP Note Template

This SOAP note template, crafted by a nurse practitioner, empowers healthcare providers to create detailed, organized clinical notes, particularly for complex cases or visits addressing multiple issues. With this template, you can:

• Document all four SOAP components: Subjective, Objective, Assessment, and Plan, including follow-up tasks like specialist referrals and patient instructions.
• Record precise patient-reported details, such as medical history, symptom descriptions, and system reviews.
• Utilize AI-powered tools to auto-generate structured SOAP notes quickly.
• Access the template and sample PDF for reference.

What is a SOAP Note Template?

A SOAP note template is a standardized framework used by healthcare professionals to document patient interactions systematically. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. This structured approach ensures concise, clear, and comprehensive clinical records, reducing documentation time and improving workflow efficiency.

This guide explores the significance of SOAP notes, their historical evolution, how to create them using templates with practical examples, and specialized templates optimized for AI-assisted documentation. Learn more about effective SOAP note practices in our blog: The Best SOAP Note Generator Software: Improving Patient Care With S10.AI Robot Medical Scribe Software.

Importance of a Well-Designed SOAP Note Template

A robust SOAP note template is essential for:

• Enhancing Clinical Decisions: Structured notes support accurate diagnoses and treatment plans.
• Facilitating Collaboration: Clear documentation ensures seamless communication across multidisciplinary healthcare teams.
• Reducing Errors: Standardized templates minimize omissions and inconsistencies in patient records.
• Saving Time: Automation reduces administrative burden, allowing clinicians to prioritize patient care.
• Legal Compliance: Comprehensive notes meet HIPAA and medical record-keeping standards, providing robust documentation for audits, insurance claims, or legal disputes.

For instance, a psychiatric SOAP note template ensures critical elements like mental status exams and E/M coding are included, streamlining documentation and improving patient outcomes. Explore more in our guide: SOAP Notes In Mental Health Examples And Best Practices.

Evolution of SOAP Note Documentation

The SOAP note format was pioneered by Dr. Lawrence L. Weed, who also introduced the first electronic medical record (EMR) system, PROMIS, in 1969. Before SOAP notes, medical documentation was often inconsistent, lacking structure and clarity, which made it challenging to track patient progress or support clinical reasoning.

With the advent of electronic health records (EHRs) in the late 1990s, SOAP notes transitioned to digital formats, improving accessibility and collaboration. Today, AI-powered tools like s10.ai have revolutionized SOAP note creation by integrating automation and voice-to-text dictation, reducing documentation time by up to 60%. For example, a primary care practice using s10.ai cut charting time by 65% within 12 weeks, saving $15,000 in administrative costs. Discover more about AI-driven documentation: AI-Generated SOAP Notes For Doctors.

How to Create Effective SOAP Notes with Examples

SOAP notes organize patient information into four key sections to ensure clarity and continuity of care. Below are guidelines for each section, accompanied by a practical example.

Subjective

This section captures patient-reported information, including:

• Chief Complaint: The primary reason for the visit, often in the patient’s own words.
• History of Present Illness (HPI): Details about symptoms, including onset, duration, severity, and aggravating/relieving factors.
• Past Medical History (PMH): Relevant medical, surgical, or psychiatric history.
• Family History: Conditions in the family that may affect the patient.
• Social History: Lifestyle factors like smoking, alcohol, or occupation.
• Review of Systems (ROS): A checklist of symptoms across body systems.

Objective

This section includes measurable data from:

• Vital Signs: Blood pressure, heart rate, temperature, etc.
• Physical Exam: Findings from head-to-toe assessments.
• Diagnostic Tests: Lab results, imaging, or other objective data.

Assessment

The clinician’s analysis, including:

• Primary Diagnosis: The most likely condition causing symptoms.
• Differential Diagnoses (DDx): Other possible conditions.
• Justification: Clinical reasoning supported by evidence or guidelines.

Plan

Actionable steps for treatment and follow-up, including:

• Medications: Prescriptions, dosages, and adjustments.
• Lifestyle Changes: Recommendations for diet, exercise, or stress management.
• Further Tests: Diagnostics to confirm or rule out conditions.
• Follow-Up: Instructions for return visits or specialist referrals.

SOAP Note Example

Subjective
Chief Complaint: “Persistent headache for 4 days.”
HPI: A 42-year-old male reports a headache starting 4 days ago, rated 7/10 in severity, localized to the temples. The pain is constant, worsens with stress, and is partially relieved by acetaminophen. He denies nausea, photophobia, or recent trauma. The patient notes increased work stress and poor sleep.
PMH: Type 2 diabetes (managed with Metformin 500 mg BID), no allergies.
Social History: Non-smoker, occasional alcohol use, works as a software engineer.
ROS: Fatigue, no vision changes, no neurological symptoms.

Objective
Vital Signs: BP 135/85 mmHg, HR 80 bpm, Temp 98.7°F, O2 Sat 97%.
General Appearance: Alert, no acute distress.
Physical Exam: HEENT: No sinus tenderness, mild temporal tenderness. Neurological: No deficits, cranial nerves intact.

Assessment
Primary Diagnosis: Tension-type headache.
DDx: Migraine (less likely due to no aura or photophobia), cluster headache (unlikely due to pain characteristics).
Justification: The bilateral, stress-related headache without neurological symptoms aligns with tension-type headache criteria.

Plan

• Start Ibuprofen 400 mg every 6 hours as needed for pain.
• Recommend stress reduction techniques (e.g., mindfulness, yoga).
• Order bloodwork to monitor diabetes and rule out other causes.
• Follow up in 10 days or sooner if symptoms escalate.

Streamline Documentation with s10.ai

s10.ai, an AI-powered medical scribe, transforms clinical documentation by generating SOAP notes in seconds. Key features include:

• Transcription: Record patient encounters with real-time, accurate transcription.
• Customization: Choose or edit templates to match your specialty.
• Automation: Generate notes, billing codes, or patient summaries instantly.

s10.ai is HIPAA-compliant and ISO-certified, trusted by clinicians for over 1.5 million patient encounters weekly. A family medicine practice reported reducing charting time from 3 hours to 45 minutes daily using s10.ai. Learn how s10.ai enhances efficiency: The Soap Note Expert.

Free SOAP Note Templates

Mental Health SOAP Note Template

This template is designed for therapists and psychologists to document behavioral, emotional, and cognitive details during therapy sessions, using a psychodynamic or object-relations approach.

Subjective

• Chief Complaint: Patient’s stated reason for visit (e.g., “Feeling overwhelmed and anxious”).
• History of Present Illness (HPI): Description of emotional, behavioral, or cognitive symptoms, including onset, duration, triggers, and coping mechanisms.
• Mental Status Exam (MSE): Observations on appearance, mood, affect, thought processes, and insight.
• Psychiatric History: Past diagnoses, hospitalizations, or therapy.
• Social History: Relationships, stressors, and support systems.
• Review of Systems (ROS): Psychological symptoms affecting mood, sleep, or cognition.

Objective

• Vital Signs: If relevant (e.g., heart rate for anxiety).
• Behavioral Observations: Posture, eye contact, speech patterns.
• Diagnostic Tools: Results from PHQ-9, GAD-7, or other standardized assessments.

Assessment

• Primary Diagnosis: E.g., Generalized Anxiety Disorder (F43.10).
• Differential Diagnoses: Other potential conditions (e.g., Adjustment Disorder, Depression).
• Justification: Based on MSE, patient history, and clinical guidelines.

Plan

• Therapy Interventions: Cognitive Behavioral Therapy (CBT), mindfulness exercises, etc.
• Medications: If prescribed, include dosage and frequency.
• Follow-Up: Schedule next session, assign therapeutic homework.
• Referrals: To psychiatrists or support groups, if needed.

Example:
Subjective: 32-year-old female reports “constant worry” for 3 weeks, triggered by work stress. Denies suicidal ideation. MSE: Anxious affect, coherent thought process.
Objective: HR 88 bpm, PHQ-9 score: 12 (moderate depression).
Assessment: Generalized Anxiety Disorder; rule out Major Depressive Disorder.
Plan: Start CBT, recommend daily journaling, follow up in 1 week.

Physical Therapy SOAP Note Template

This template is built for physiotherapists to track patient progress, exercise adherence, and symptoms in outpatient settings.

Subjective

• Chief Complaint: Patient’s reported issue (e.g., “Knee pain when walking”).
• History of Present Illness (HPI): Pain characteristics, functional limitations, and response to prior treatments.
• Patient Goals: Desired outcomes (e.g., return to sports).
• Adherence: Compliance with home exercise program (HEP).

Objective

• Vital Signs: If relevant (e.g., blood pressure post-exercise).
• Physical Exam: Range of motion (ROM), strength, gait, and palpation findings.
• Functional Tests: E.g., 6-minute walk test or balance assessments.
• Progress Metrics: Improvement in pain scale or mobility.

Assessment

• Primary Diagnosis: E.g., Patellofemoral Pain Syndrome.
• Differential Diagnoses: E.g., Meniscal injury, osteoarthritis.
• Justification: Based on exam findings and functional limitations.

Plan

• Interventions: Manual therapy, therapeutic exercises, or modalities (e.g., ultrasound).
• Home Exercise Program (HEP): Specific exercises with frequency and reps.
• Follow-Up: Schedule next session, monitor progress.
• Referrals: To orthopedists, if needed.

Example:
Subjective: 45-year-old male reports right knee pain (4/10) for 2 months, worse with stairs. Adheres to 80% of HEP.
Objective: ROM: 0-110°, strength 4/5 quadriceps, mild swelling.
Assessment: Patellofemoral Pain Syndrome; rule out meniscal tear.
Plan: Continue quadriceps strengthening, add ice therapy, follow up in 2 weeks.

Family Medicine SOAP Note Template

This template supports holistic documentation for initial and follow-up visits in family medicine, capturing comprehensive patient data.

Subjective

• Chief Complaint: Primary concern (e.g., “Fatigue and cough”).
• History of Present Illness (HPI): Symptom details, onset, and associated factors.
• Past Medical History (PMH): Chronic conditions, surgeries, allergies.
• Family History: Relevant hereditary conditions.
• Social History: Lifestyle factors (e.g., smoking, occupation).
• Review of Systems (ROS): Symptoms across body systems.

Objective

• Vital Signs: BP, HR, RR, Temp, O2 Sat.
• Physical Exam: Head-to-toe findings (e.g., HEENT, cardiovascular).
• Diagnostic Tests: Lab results, imaging, or EKGs.

Assessment

• Primary Diagnosis: E.g., Upper Respiratory Infection.
• Differential Diagnoses: E.g., Allergies, bronchitis.
• Justification: Based on clinical findings and history.

Plan

• Medications: Prescriptions or adjustments.
• Lifestyle Modifications: Diet, exercise, or smoking cessation.
• Further Tests: To confirm diagnosis or monitor conditions.
• Follow-Up: Return visit or specialist referral.

Example:
Subjective: 50-year-old female reports fatigue and dry cough for 1 week. PMH: Hypertension.
Objective: BP 130/80, HR 76, Temp 98.6°F, clear lungs.
Assessment: Viral URI; rule out allergic rhinitis.
Plan: Rest, hydration, OTC antihistamine, follow up in 7 days if no improvement.

Primary Care SOAP Note Template

This template streamlines documentation for nurse practitioners in primary care, focusing on efficient symptom assessment and treatment planning.

Subjective

• Chief Complaint: Patient’s main issue (e.g., “Sore throat”).
• History of Present Illness (HPI): Symptom onset, severity, and management.
• Past Medical History (PMH): Relevant conditions and medications.
• Social History: Lifestyle factors impacting health.
• Review of Systems (ROS): Additional symptoms.

Objective

• Vital Signs: BP, HR, Temp, etc.
• Physical Exam: Focused findings (e.g., throat, lymph nodes).
• Diagnostic Tests: Rapid strep test, bloodwork, etc.

Assessment

• Primary Diagnosis: E.g., Streptococcal Pharyngitis.
• Differential Diagnoses: E.g., Viral pharyngitis, tonsillitis.
• Justification: Based on test results and exam.

Plan

• Medications: Antibiotics or symptomatic relief.
• Patient Education: Instructions for medication or self-care.
• Follow-Up: Return visit or escalation criteria.

Example:
Subjective: 28-year-old male reports sore throat for 3 days, difficulty swallowing. No allergies.
Objective: Temp 99.8°F, throat erythematous, positive rapid strep test.
Assessment: Streptococcal Pharyngitis.
Plan: Amoxicillin 500 mg BID for 10 days, follow up in 1 week.

Acupuncture SOAP Note Template

This template helps acupuncturists document client visits, capturing subjective symptoms, objective findings, and treatment details.

Subjective

• Chief Complaint: Client’s primary concern (e.g., “Chronic back pain”).
• History of Present Illness (HPI): Pain characteristics, triggers, and prior treatments.
• Medical History: Relevant conditions or medications.
• Lifestyle Factors: Stress, diet, or sleep patterns.

Objective

• Vital Signs: If relevant (e.g., pulse for TCM diagnosis).
• Physical Exam: Palpation, tongue/pulse diagnosis, or mobility assessment.
• Observations: Skin condition, posture, or energy levels.

Assessment

• Primary Diagnosis: E.g., Qi stagnation causing back pain.
• Differential Diagnoses: E.g., Muscle strain, disc issue.
• Justification: Based on TCM principles and clinical findings.

Plan

• Acupuncture Points: Specific points used (e.g., BL23, GV4).
• Additional Therapies: Cupping, moxibustion, or gua sha.
• Lifestyle Recommendations: Stretching, dietary changes.
• Follow-Up: Next session or progress evaluation.

Example:
Subjective: 35-year-old female reports lower back pain (6/10) for 6 months, worse with prolonged sitting.
Objective: Tongue: Pale, pulse: Wiry. Tender at BL23.
Assessment: Qi stagnation in Bladder meridian.
Plan: Acupuncture at BL23, BL40, cupping, follow up in 1 week.

FAQs about SOAP Note Templates

What are the key components of a SOAP note?

A SOAP note includes Subjective (patient-reported symptoms), Objective (clinical findings), Assessment (diagnosis and reasoning), and Plan (treatment and follow-up). This format ensures comprehensive and standardized documentation.

How can I create a custom SOAP note template?

With s10.ai, clinicians can import pre-built templates or upload a sample note to create AI-enabled, editable templates. Pro users enjoy unlimited template customization and access to s10.ai’s AI chatbot for workflow optimization. Learn More.

Are SOAP note templates editable?

Yes, s10.ai offers editable templates tailored to various specialties. Browse the template community, customize formats, and integrate them into your workflow.

How does AI improve SOAP note documentation?

AI tools like s10.ai automate transcription, suggest billing codes, and generate structured notes, reducing documentation time by up to 60% and minimizing errors. Read more: The Best SOAP Note Generator Software.

Can SOAP notes support legal and billing purposes?

Yes, well-structured SOAP notes comply with HIPAA and medical record standards, providing robust documentation for audits, insurance claims, and legal protection.

What specialties benefit from SOAP note templates?

Specialties like psychiatry, physical therapy, family medicine, primary care, and acupuncture benefit from tailored templates that streamline documentation and enhance patient care.

How does s10.ai ensure data security?

s10.ai is HIPAA-compliant and ISO-certified, ensuring patient data is secure and meets global privacy standards. Explore s10.ai Features.

How are pediatric SOAP notes different from standard SOAP notes?

Pediatric SOAP Note Template

When documenting for pediatric patients, SOAP notes require additional nuance. Children often can't fully articulate their symptoms, so information is gathered from both the child and their caregiver. Growth, development, and vaccination status become central, and assessments are tailored to age-specific milestones.

Subjective

Chief Complaint: Reason for visit, as described by parent or guardian (“Fever and fussiness”).

History of Present Illness (HPI): Include onset, duration, feeding habits, sleep, behavior changes, and others’ observations.

Birth and Developmental History: Milestones, prenatal/perinatal concerns, school or daycare attendance.

Social/Family History: Household exposures, daycare setting, siblings’ health, family medical history.

Immunization Status: Up-to-date or missing vaccines.

Objective

Vital Signs: Age-appropriate ranges; include weight, height, head circumference in infants.

Physical Exam: Gentle exam noting appearance, hydration status, rashes, or abnormal cries.

Behavioral Observations: Mood, interaction with caregiver, response to exam.

Assessment

Diagnosis Considerations: Includes infectious diseases, developmental delays, or common pediatric conditions.

Growth/Development Review: Check against age norms and flag any parental concerns.

Plan

Medications/Dosing: Calculate by weight (mg/kg), emphasizing safety.

Parent Education: Symptom monitoring, warning signs, and home care instructions.

Vaccinations: Update if due, document discussion.

Follow-Up: Guidance for when to return or seek care.

      Example:

      Subjective: 2-year-old boy brought in by mother for fever (101.5°F) and decreased appetite. No vomiting. Immunizations current.

      Objective: Temp 101.5°F, weight 27 lbs, alert, hydrated, mild erythema in throat, no rashes.

      Assessment: Viral pharyngitis, well child; no signs of serious illness.

      Plan: Encourage fluids, acetaminophen as needed, monitor for lethargy or difficulty breathing, follow up in 48 hours if symptoms persist.

How long is a typical SOAP note?

How Long Is a Typical SOAP Note?

A typical SOAP note is designed to be focused and efficient, often fitting onto a single page. For most patient encounters, the note spans just a few well-organized paragraphs—long enough to capture essential details without becoming unwieldy. The actual length may increase with complex cases, but clear, concise documentation remains the goal, ensuring quick reference for any provider reviewing the patient’s history.

What tips can help clinicians write effective and concise SOAP notes?

What are the key components of a SOAP note?

A SOAP note includes Subjective (patient-reported symptoms), Objective (clinical findings), Assessment (diagnosis and reasoning), and Plan (treatment and follow-up). This format ensures comprehensive and standardized documentation.

 To keep your SOAP notes both effective and manageable, aim to spend just 5 to 7 minutes writing each one. It’s often helpful to jot them down between sessions rather than letting them pile up at the end of the day. Remember, brevity isn’t about skipping details—it’s about focusing on what matters most. Comprehensiveness is more important than length: a concise, two-sentence section can be just as effective as a longer one if it covers the essential information.

 When documenting, don’t stress about recording every single detail from the session. Instead, concentrate on information that supports your client’s diagnosis, demonstrates the ongoing need for treatment, and justifies the approach you are using. This not only meets insurance requirements but also streamlines your workflow and supports your self-care as a clinician.

What information is most important to include in SOAP notes for insurance and compliance purposes?

Yes, well-structured SOAP notes comply with HIPAA and medical record standards, providing robust documentation for audits, insurance claims, and legal protection.

 To further support billing and legal requirements, each SOAP note section should clearly document the essential clinical details—such as session start and stop times, place of service, and elements like a brief mental status exam or risk assessment when relevant. Many clinicians enhance the Subjective section with a direct client quote, which helps demonstrate the session’s authenticity to insurers.

 Rather than capturing every single detail, focus on information that substantiates the diagnosis, ongoing treatment needs, and the clinical approach used. This targeted documentation not only satisfies compliance but also streamlines the process for insurance claims and legal review.

How much time should it take to write a SOAP note?

Today, AI-powered tools like s10.ai have revolutionized SOAP note creation by integrating automation and voice-to-text dictation, reducing documentation time by up to 60%. For example, a primary care practice using s10.ai cut charting time by 65% within 12 weeks, saving $15,000 in administrative costs.

It’s still wise to keep in mind some classic documentation best practices: many clinicians find that planning for 5 to 7 minutes per progress note helps them stay efficient without sacrificing accuracy. Fitting in notes between sessions—rather than letting them pile up—prevents that end-of-day documentation backlog. As one experienced provider puts it, “Learning how to write concise but accurate notes is such an important skill, just for your own self care as a provider.” Combining time-tested habits with modern AI solutions can dramatically improve both workflow and well-being.

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