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SOAP Note Examples 2026Free PDF Templates for All Specialties

Comprehensive SOAP note examples for primary care, mental health, physical therapy, emergency medicine, and nursing. Learn best practices with real clinical examples.

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What Is a SOAP Note?SOAP Structure Guide Primary Care Example Mental Health Example Physical Therapy Example Emergency Example Nursing Example FAQ

What Is a SOAP Note?

A SOAP note is a structured method for documenting patient encounters developed by Dr. Lawrence Weed in the 1960s. SOAP stands for Subjective, Objective, Assessment, and Plan - four sections that organize clinical information logically.

Research shows that standardized SOAP documentation can reduce medical errors by up to 25% and improve patient outcomes by 20-30%. The format ensures clear communication between healthcare teams and supports clinical decision-making.

Standardized Format

Consistent structure enables all healthcare providers to quickly find relevant information regardless of specialty.

Legal Protection

Thorough documentation protects providers in malpractice cases and ensures compliance with regulations.

Continuity of Care

Clear documentation enables seamless handoffs and helps future providers understand patient history.

SOAP Note Structure Guide

Subjective

Patient-reported information and history

-Chief Complaint (CC) - reason for visit in patient's words

-History of Present Illness (HPI) - OLDCARTS format

-Past Medical History (PMH)

-Medications and Allergies

-Social History (SH) and Family History (FH)

-Review of Systems (ROS)

Objective

Measurable, observable clinical findings

-Vital Signs (BP, HR, RR, Temp, SpO2, Weight)

-Physical Examination findings by system

-Mental Status Exam (psychiatric)

-Laboratory results

-Imaging findings

-Standardized assessment scores

Assessment

Clinical judgment and diagnosis

-Primary diagnosis with ICD-10 code

-Secondary diagnoses

-Differential diagnosis (if uncertain)

-Problem list updates

-Clinical reasoning

-Prognosis discussion

Plan

Treatment plan and next steps

-Medications (name, dose, route, frequency)

-Procedures ordered or performed

-Diagnostic tests ordered

-Referrals

-Patient education provided

-Follow-up instructions and timing

Primary Care

Primary Care SOAP Note Example

Acute Upper Respiratory Infection

Subjective

CC: "I've had a sore throat and runny nose for 3 days."

HPI: 45 y/o female presents with 3-day history of nasal congestion, sore throat, clear rhinorrhea, and mild non-productive cough. Denies fever, chills, ear pain, or difficulty swallowing. Has tried OTC acetaminophen with partial relief. No sick contacts at home.

PMH: Hypertension (controlled), seasonal allergies
Medications: Lisinopril 10mg daily, loratadine PRN
Allergies: NKDA
ROS: Positive for symptoms above. Negative for headache, ear pain, chest pain, SOB.

Objective

Vitals: BP 128/82, HR 76, RR 16, Temp 98.6°F, SpO2 99% RA
General: Alert, NAD, appears well
HEENT: TMs clear bilaterally, mild pharyngeal erythema without exudate, nasal turbinates mildly swollen, no sinus tenderness
Neck: No lymphadenopathy
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
Heart: RRR, no murmurs

Assessment

1. Acute viral upper respiratory infection (J06.9)
2. Hypertension, controlled (I10)

Clinical reasoning: Presentation consistent with viral URI. No signs of bacterial sinusitis or streptococcal pharyngitis.

Plan

1. Symptomatic treatment:
   - Acetaminophen 650mg PO q6h PRN pain/fever
   - Pseudoephedrine 30mg PO q6h PRN congestion x 5 days
   - Increase oral fluids, rest
2. Return precautions: fever >101°F, symptoms >10 days, difficulty breathing
3. No antibiotics indicated at this time
4. Continue home medications
5. Follow-up PRN or if symptoms worsen

Mental Health

Mental Health SOAP Note Example

Major Depressive Disorder Follow-up

Subjective

CC: Follow-up for depression management

HPI: 32 y/o male presents for 4-week follow-up since starting sertraline. Reports "feeling a little better" - mood improved from 3/10 to 5/10 over past 2 weeks. Sleep improved, now getting 6-7 hours (previously 4-5). Appetite returning. Denies SI/HI. Completed therapy homework (daily mood tracking). Still experiencing low motivation and difficulty concentrating at work.

Social: Working full-time, supportive partner at home. Denies alcohol/substance use.
Medications: Sertraline 50mg daily x 4 weeks

Objective

Mental Status Exam:
- Appearance: Casually dressed, appropriate hygiene
- Behavior: Good eye contact, cooperative
- Mood: "Better, not great"
- Affect: Constricted but reactive, congruent
- Speech: Normal rate, rhythm, volume
- Thought Process: Linear, goal-directed
- Thought Content: No SI/HI, no delusions
- Cognition: Alert, oriented x4
- Insight/Judgment: Good/Good

PHQ-9: 12 (moderate) - improved from 18 at baseline
GAD-7: 8 (mild anxiety)

Assessment

1. Major Depressive Disorder, single episode, moderate - improving (F32.1)
2. Generalized Anxiety Disorder (F41.1)

Patient showing partial response to sertraline 50mg after 4 weeks. No adverse effects reported. Continue current dose or consider increase.

Plan

1. Increase sertraline to 100mg daily
2. Continue weekly CBT with therapist
3. Maintain mood tracking homework
4. Safety plan reviewed - patient to call crisis line or present to ED if SI
5. Return in 4 weeks
6. Discussed expected timeline for full response (6-8 weeks at therapeutic dose)

Physical Therapy

Physical Therapy SOAP Note Example

Acute Low Back Pain

Subjective

CC: "My lower back has been killing me for a week"

HPI: 38 y/o male referred for PT evaluation of acute LBP. Pain began 7 days ago after lifting heavy box at work. Describes constant dull ache in lower lumbar region rated 7/10, with sharp pain 8/10 with bending. Pain radiates to right buttock but not below knee. Worse with sitting >30 min, bending, lifting. Better with lying flat, ice, ibuprofen.

Functional Limitations: Unable to tie shoes, difficulty with prolonged sitting at desk, cannot lift >10 lbs
Goals: Return to work without restrictions, resume gym workouts
Prior Treatment: Using ice, ibuprofen 400mg TID with moderate relief

Objective

Vitals: HR 72, BP 124/78
Posture: Slight right lateral shift, decreased lumbar lordosis
Gait: Antalgic, shortened stride length on right
AROM Lumbar:
- Flexion: 40% (pain at end range)
- Extension: 60% (centralization of symptoms)
- Side-bending: 70% bilateral
- Rotation: 80% bilateral

Special Tests:
- SLR: Negative bilaterally
- FABER: Negative bilaterally
- Prone instability test: Negative

Palpation: Tenderness L4-L5 paraspinals right > left
Neurological: Sensation intact L1-S1, strength 5/5 B LE, reflexes 2+ bilateral

Oswestry Disability Index: 44% (moderate disability)

Assessment

1. Acute mechanical low back pain with directional preference for extension
2. No signs of radiculopathy or neurological involvement
3. Good prognosis for recovery with conservative management

Short-term goals (2 weeks): Pain 4/10, sit 60 minutes without increase
Long-term goals (6 weeks): Return to full work duties, resume exercise

Plan

1. Manual therapy: Lumbar mobilization grades II-III
2. Therapeutic exercises:
   - Prone press-ups 3x10 every 2 hours
   - Pelvic tilts 3x15
   - Cat-camel stretches 2x10
3. Patient education: Posture, body mechanics, ergonomics
4. Modalities: Ice 15 min post-exercise
5. Frequency: 2x/week for 4 weeks
6. Home exercise program provided
7. Will reassess in 2 weeks for progression

Emergency Department

Emergency Department SOAP Note Example

Chest Pain Evaluation

Subjective

CC: "Chest pain for 2 hours"

HPI: 58 y/o male presents with 2-hour history of substernal chest pressure described as "heavy" and rated 7/10. Pain radiates to left arm and jaw. Associated with diaphoresis and nausea. Onset while watching TV at rest. No relief with antacids. Denies SOB, palpitations, syncope.

PMH: HTN x 10 years, hyperlipidemia, T2DM, former smoker (quit 5 years ago, 20 pack-year history)
Medications: Metformin 1000mg BID, atorvastatin 40mg daily, lisinopril 20mg daily
Allergies: Penicillin (rash)
FH: Father MI at age 55

Objective

Vitals: BP 158/95, HR 92, RR 18, Temp 98.4°F, SpO2 97% RA
General: Anxious, diaphoretic, in moderate distress
CV: Regular rate, S1/S2 normal, no murmurs, no JVD
Lungs: Clear bilaterally, no rales
Abd: Soft, non-tender
Ext: No edema, pulses 2+ bilaterally

ECG: ST elevations V2-V5, ST depression II, III, aVF
Troponin I: 0.8 ng/mL (H) - ref <0.04
BMP: Normal
CBC: WBC 11.2, Hgb 14.5

Assessment

1. ST-Elevation Myocardial Infarction (STEMI) - Anterior wall (I21.0)
2. Hypertension (I10)
3. Type 2 Diabetes Mellitus (E11.9)
4. Hyperlipidemia (E78.5)

HEART Score: 8 (High risk)

Plan

1. STEMI Protocol activated - Cardiology notified
2. ASA 325mg PO given
3. Heparin bolus 60 units/kg IV, gtt initiated
4. Ticagrelor 180mg PO loading dose
5. Nitroglycerin SL x3, then gtt for persistent chest pain
6. Morphine 4mg IV for pain
7. O2 via NC to maintain SpO2 >94%
8. Serial troponins, repeat ECG
9. Emergent cardiac catheterization - patient to cath lab
10. Family updated, consents obtained

Nursing

Nursing SOAP Note Example

Post-operative Day 1 Assessment

Subjective

Patient reports pain at surgical site rated 5/10, improved from 8/10 yesterday with current pain regimen. Describes pain as "sore and tight." Denies nausea, vomiting, or dizziness. Reports passing flatus this morning. States feeling "tired but okay." Concerned about when she can shower.

Sleep: Interrupted due to vital checks, slept approximately 4 hours
Appetite: Tolerating clear liquids, requesting regular diet
Mobility: "I walked twice yesterday in the hall with the nurse"

Objective

Vitals: BP 122/78, HR 76, RR 16, Temp 98.8°F, SpO2 98% RA, Pain 5/10
General: Alert, oriented x4, appears fatigued
Neuro: PERRLA, moves all extremities, follows commands
CV: RRR, no murmurs, peripheral pulses present, no edema
Resp: Clear to auscultation, no distress, incentive spirometry to 1500mL
GI: Abdomen soft, mild tenderness at incision, + bowel sounds all quadrants, flatus present
GU: Foley catheter draining clear yellow urine, output 350mL over 8 hours
Surgical Site: Right lower quadrant, dressing clean/dry/intact, no drainage noted
Skin: Warm, dry, intact, SCDs in place bilaterally

I&O (24h): Intake 2100mL, Output 1850mL (urine 1600mL, JP drain 250mL)
Labs: WBC 10.2, Hgb 11.8 (down from 13.2 pre-op)

Assessment

POD 1 s/p laparoscopic appendectomy
1. Acute post-operative pain - controlled with current regimen
2. Risk for infection - WBC slightly elevated but trending down
3. Impaired mobility - ambulating with assistance
4. Knowledge deficit regarding post-op care

Plan

1. Pain: Continue hydrocodone-acetaminophen 5-325mg PO q4-6h PRN
2. Activity: Ambulate TID with assistance, progress as tolerated
3. Diet: Advance to regular diet as tolerated
4. Foley: D/C today per protocol if voiding adequate
5. DVT prophylaxis: Continue SCDs, heparin 5000 units SQ q8h
6. Respiratory: Continue incentive spirometry q1h while awake
7. Wound care: Education on incision care, signs of infection
8. Discharge planning: Anticipate discharge POD 2 if no complications
9. Notify MD: Temp >101.3°F, increased pain, wound drainage, decreased UOP

SOAP Note Best Practices

Do This

- Use patient's own words in Subjective
- Include measurable data in Objective
- State diagnosis clearly in Assessment
- Include specific medications with dosages
- Document patient education provided
- Include clear follow-up instructions
- Be concise but thorough
- Sign and date all notes

Avoid This

- Using vague language ("patient appears sick")
- Mixing subjective and objective information
- Copying forward without updating
- Using prohibited abbreviations
- Leaving sections blank without notation
- Including personal opinions or judgments
- Documenting late without noting it
- Using illegible handwriting (if paper)

Frequently Asked Questions

What is a SOAP note?

A SOAP note is a structured documentation method used by healthcare providers. SOAP stands for Subjective (patient's symptoms and history), Objective (measurable findings like vitals and exam results), Assessment (diagnosis and clinical judgment), and Plan (treatment, medications, follow-up). Developed by Dr. Lawrence Weed in the 1960s, it remains the gold standard for clinical documentation.

How do I write a good SOAP note?

To write a good SOAP note: 1) Subjective - Use patient's own words, document chief complaint, HPI, and relevant history; 2) Objective - Record vitals, physical exam findings, and test results with measurable data; 3) Assessment - State diagnosis clearly, include differential if uncertain; 4) Plan - Detail treatment, medications with dosages, patient education, and follow-up timeline. Be concise, specific, and avoid vague language.

What should be included in the Subjective section?

The Subjective section should include: Chief Complaint (CC) in patient's words, History of Present Illness (HPI) with onset, location, duration, character, aggravating/relieving factors, and timing. Also include relevant past medical history, medications, allergies, social history, family history, and Review of Systems (ROS). Use direct quotes when possible.

What goes in the Objective section of a SOAP note?

The Objective section contains measurable, observable data: Vital signs (BP, HR, RR, temp, SpO2, weight), physical examination findings by system, mental status exam (for psychiatric notes), laboratory and imaging results, and any standardized assessment scores (PHQ-9, GAD-7, pain scales). Document what you can see, hear, measure, or verify independently.

How is a mental health SOAP note different?

Mental health SOAP notes include: Subjective - Patient's mood description, symptoms, stressors, therapy homework completion; Objective - Mental Status Exam (appearance, behavior, mood, affect, thought process/content, cognition, insight, judgment), standardized scales (PHQ-9, GAD-7); Assessment - DSM-5 diagnosis, symptom severity, risk assessment; Plan - Therapeutic interventions used, homework assigned, medication changes, safety planning, next session.

Can I use AI to help write SOAP notes?

Yes, AI-powered ambient scribes like PatientNotes can automatically generate SOAP notes from patient conversations. Studies show AI reduces documentation time by 50% and can improve note quality. AI tools listen to the encounter and generate a draft note that the provider reviews and signs off on, allowing more time for patient care and reducing burnout.

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SOAP Note Examples 2026Free PDF Templates for All Specialties

In This Guide

What Is a SOAP Note?

Standardized Format

Legal Protection

Continuity of Care

SOAP Note Structure Guide

Subjective

Objective

Assessment

Plan

Primary Care SOAP Note Example

Subjective

Objective

Assessment

Plan

Mental Health SOAP Note Example

Subjective

Objective

Assessment

Plan

Physical Therapy SOAP Note Example

Subjective

Objective

Assessment

Plan

Emergency Department SOAP Note Example

Subjective

Objective

Assessment

Plan

Nursing SOAP Note Example

Subjective

Objective

Assessment

Plan

SOAP Note Best Practices

Do This

Avoid This

Frequently Asked Questions

What is a SOAP note?

How do I write a good SOAP note?

What should be included in the Subjective section?

What goes in the Objective section of a SOAP note?

How is a mental health SOAP note different?

Can I use AI to help write SOAP notes?

Generate SOAP Notes Automatically

Related Resources

SOAP Notes Guide

Progress Notes Guide

DAP Notes Guide