SOAP Notes Examples

A list of SOAP Note examples for clinicians in the USA. Download Free SOAP Notes Templates [2025 updated]

Whether you’re a medical student, a seasoned practitioner, or a nurse, SOAP notes ensure clear communication, continuity of care, and accurate documentation. Let’s dive into the SOAP format, its purpose, and how to craft concise, impactful notes that reflect both your clinical reasoning and your patient’s story.

What Are SOAP Notes, and Why Do They Matter?

SOAP notes are structured documentation that helps clinicians organize patient information methodically. The beauty of the SOAP format lies in its simplicity: it provides a universal framework for recording everything from a patient’s complaints to your diagnosis and plan. This structure isn’t just for efficiency; it’s a way to ensure we don’t miss critical details, making care safer and more comprehensive.

Think of SOAP notes as both a roadmap and a story. They capture:

What the patient feels and says.
What you observe and measure.
How you interpret the findings.
What you’ll do to address the problem.

SOAP Note Format

1. Subjective: Tuning In to the Patient’s Story

This is the “listening” part of your interaction. Here, you record what the patient tells you in their own words. What brought them in today? How are they feeling? What’s changed since their last visit? If the patient’s caregiver or family member provides input, include that too.

What to Include:

Chief Complaint (CC): The reason they’re seeking care—keep it short and specific.
Example: “I’ve had a sharp pain in my chest for two days.”
History of Present Illness (HPI): Details of the chief complaint. Use the “OLD CARTS” mnemonic: Onset, Location, Duration, Characteristics, Aggravating/Relieving factors, Timing, and Severity.
Example: “The pain started suddenly after exercising, feels sharp, and worsens when I take deep breaths.”
Relevant History: Include any pertinent medical, social, or family history.
Example: “History of hypertension; father died of a heart attack at 50.”
Review of Systems (ROS): Ask about related symptoms.
Example: “No fever, nausea, or difficulty breathing.”

2. Objective: Observing with a Clinician’s Eye

The “objective” section is where science meets observation. This part is all about measurable and observable data—what you can quantify or see during your exam or from diagnostic tests.

What to Include:

Vital Signs: These are your foundation—always start here.
Example: “BP 140/90, HR 90 bpm, Temp 98.7°F.”
Physical Exam Findings: Describe what you see, hear, and feel during the examination.
Example: “Lungs clear bilaterally; tenderness noted over the left chest wall.”
Diagnostics: Note any available results from labs or imaging.
Example: “EKG shows no abnormalities; chest X-ray pending.”

3. Assessment: Tying It All Together

This is where you make sense of the puzzle. Think of the assessment as your clinical reasoning boiled down into a clear summary. Based on the subjective and objective findings, what do you think is going on? If you’re not certain, that’s okay—include a differential diagnosis (a list of possible conditions).

What to Include:

Primary Diagnosis: What’s most likely happening?
Example: “Costochondritis (inflammation of the chest wall).”
Supporting Evidence: Show your thought process.
Example: “Sharp, localized chest pain, tender to palpation, no cardiac abnormalities on EKG.”
Differentials (if needed): Other potential diagnoses.
Example: “Rule out pulmonary embolism or myocardial infarction.”

4. Plan: Turning Insight into Action

The “plan” is where your expertise shines. This section outlines the next steps for managing the patient’s condition. It’s your blueprint for treatment, follow-up, and patient education.

What to Include:

Medications: What are you prescribing?
Example: “Ibuprofen 400 mg every 8 hours for 5 days.”
Procedures: Any treatments or interventions you performed or ordered.
Example: “Chest X-ray ordered; results to be reviewed at follow-up.”
Patient Education: How will you ensure the patient understands their condition and treatment?
Example: “Reassured patient that costochondritis is benign; advised rest and avoidance of heavy lifting.”
Follow-Up: When should the patient return or check in?
Example: “Follow up in 1 week if symptoms persist or worsen.”

SOAP Note in Practice: An Example

Here’s how all the pieces come together:

Patient Name: John Doe
Date: 11/26/2024
Visit Type: Follow-up for chest pain

Subjective:
John reports sharp chest pain over the left side for two days. The pain started after lifting heavy boxes at work. It worsens with deep breathing but improves with rest. Denies shortness of breath, fever, or nausea. He has a history of hypertension but no prior cardiac issues.

Objective:

BP: 140/90, HR: 90 bpm, Temp: 98.7°F.
Chest exam: Tenderness over the left second rib; no swelling or deformity. Lungs clear bilaterally.
Diagnostics: EKG normal; chest X-ray pending.

Assessment:

Primary Diagnosis: Costochondritis.
Supporting Evidence: Localized chest pain reproducible with palpation; normal EKG.
Differential Diagnoses: Pulmonary embolism (low likelihood), myocardial infarction (ruled out with EKG).

Plan:

Prescribe ibuprofen 400 mg every 8 hours for 5 days.
Advise rest and avoid heavy lifting.
Reassure patient about benign nature of condition.
Follow up in 1 week if symptoms persist or worsen.

Tips for Writing Exceptional SOAP Notes

Be Clear and Concise: Use straightforward language and avoid unnecessary jargon.
Stay Objective: Especially in the “Objective” and “Assessment” sections, let the evidence guide your reasoning.
Incorporate the Patient’s Voice: The “Subjective” section should reflect the patient’s concerns and language.
Show Your Clinical Reasoning: In the “Assessment” section, explain why you reached a particular conclusion.
Tailor the Plan: Ensure it’s practical, patient-centered, and includes clear instructions.

Why SOAP Notes Are More Than Just Documentation

SOAP notes are more than a legal requirement or a communication tool—they’re a reflection of the art and science of medicine. They showcase your ability to listen to patients, synthesize information, and create actionable solutions. Writing great SOAP notes isn’t just about recording information; it’s about storytelling with a purpose—capturing the journey from symptoms to solutions.

SOAP Notes Examples

1. SOAP Notes Example for General Medical Checkup

Instructions:

Focus on the patient’s primary complaints (if any), review systems comprehensively, and document objective findings like vital signs and physical examination. Keep the assessment general unless specific issues are raised.

SOAP Note:

Subjective: Patient reports fatigue and mild headaches over the past two weeks. No associated symptoms like fever, chills, or significant stress reported. Denies changes in diet, exercise, or sleep patterns.
Objective: BP 120/80, HR 70 bpm, Temp 98.6°F. Physical exam shows no abnormalities.
Assessment: Likely mild dehydration or stress-related fatigue. No significant findings warranting further investigation at this time.
Plan: Encourage hydration (2–3 L/day), recommend multivitamin supplementation, and advise follow-up in two weeks if symptoms persist.

2. SOAP Notes Example for Pediatric Fever

Instructions:

For pediatric patients, include parental observations and history of recent illnesses or exposures. Document objective findings specific to infection (e.g., temperature, throat exam).

SOAP Note:

Subjective: Parent reports fever (101°F) for two days with a mild cough and runny nose. No vomiting or diarrhea. Normal appetite and hydration.
Objective: Temp 100.9°F, HR 100 bpm. Throat erythematous without exudate, lungs clear bilaterally, and tympanic membranes normal.
Assessment: Viral upper respiratory infection.
Plan: Supportive care: Ensure hydration, administer acetaminophen for fever, monitor for worsening symptoms (e.g., breathing difficulty or high fever). Follow up in 3–5 days if no improvement.

3. SOAP Notes Example for Diabetes Management

Instructions:

Track blood sugar trends and evaluate any complications or side effects of medications. Adjust the treatment plan based on the patient’s glucose control and lifestyle changes.

SOAP Note:

Subjective: Patient reports good insulin compliance but notes occasional episodes of hypoglycemia after evening meals. No other complaints.
Objective: FBG 120 mg/dL, HbA1c 7.0%, weight stable. Foot exam normal.
Assessment: Well-controlled Type 2 diabetes with minor need for insulin dose adjustment.
Plan: Decrease nighttime insulin dose by 2 units, review dietary intake (especially dinner carbohydrate levels), and encourage regular exercise. Follow up in 3 months with HbA1c.

4. SOAP Notes Example for Hypertension Follow-Up

Instructions:

Document blood pressure readings, current medication adherence, and any side effects. Include any recent changes in lifestyle that might impact BP.

SOAP Note:

Subjective: Patient reports no side effects from antihypertensive medication but notes occasional morning light-headedness.
Objective: BP 140/90, HR 80 bpm. No murmurs or bruits heard. Labs: normal renal function and electrolytes.
Assessment: Controlled hypertension with potential over-medication.
Plan: Adjust antihypertensive dose to lower morning symptoms, recommend home BP monitoring, and advise regular exercise. Follow up in 4 weeks.

5. SOAP Notes Example for Acute Asthma Exacerbation

Instructions:

Capture the trigger, severity, and previous asthma control. Include detailed respiratory exam findings, oxygen saturation, and immediate interventions.

SOAP Note:

Subjective: Patient reports sudden onset of shortness of breath and wheezing after cleaning (dust exposure). Rescue inhaler used once with no relief.
Objective: RR 24, SpO2 92% on room air, wheezing on auscultation bilaterally.
Assessment: Acute asthma exacerbation triggered by environmental allergens.
Plan: Administer albuterol nebulizer every 20 minutes for 1 hour, prescribe prednisone (40 mg daily x 5 days), and educate on trigger avoidance. Schedule follow-up in 1 week.

6. SOAP Notes Example for Chronic Pain

Instructions:

Emphasize the patient’s pain location, severity, and functional impact. Document any neurologic findings and imaging results if available.

SOAP Note:

Subjective: Patient reports persistent lower back pain (7/10) over the past month, worsened by prolonged sitting.
Objective: Tenderness at L4-L5, normal gait, negative straight leg raise.
Assessment: Chronic low back pain likely due to degenerative disc disease.
Plan: Refer to physical therapy, consider MRI to rule out structural abnormalities, and prescribe NSAIDs (e.g., ibuprofen 600 mg TID).

7. SOAP Notes Example for Post-Surgical Follow-Up

Instructions:

Focus on post-operative symptoms like pain, signs of infection, and wound healing. Include any dressing or suture changes.

SOAP Note:

Subjective: Patient reports mild pain at incision site but denies fever, swelling, or redness.
Objective: Incision is clean, dry, and intact with no signs of erythema or drainage.
Assessment: Normal post-operative recovery.
Plan: Continue wound care, acetaminophen (500 mg as needed), and advise follow-up in 2 weeks.

8. SOAP Notes Example for Urinary Tract Infection

Instructions:

Include classic UTI symptoms, recent sexual activity (if appropriate), and urinalysis results. Note systemic signs of infection.

SOAP Note:

Subjective: Patient complains of dysuria and urinary frequency for two days, denies fever or flank pain.
Objective: UA positive for leukocytes and nitrates. Temp 99.0°F.
Assessment: Uncomplicated UTI.
Plan: Prescribe 3-day antibiotic course (e.g., nitrofurantoin), encourage hydration, and follow up if symptoms persist.

9. SOAP Notes Example for Anxiety Disorder

Instructions:

Assess symptom frequency, triggers, and functional impact. Use validated tools like GAD-7 for severity scoring.

SOAP Note:

Subjective: Patient reports daily anxiety, racing thoughts, and trouble sleeping for 3 months.
Objective: GAD-7 score: 12, normal physical exam.
Assessment: Generalized anxiety disorder (moderate severity).
Plan: Begin sertraline (25 mg daily), recommend CBT, and follow up in 4 weeks to assess medication efficacy.

10. SOAP Notes Example for Headache

Instructions:

Document the type, severity, and location of the headache. Rule out red flags like visual changes, fever, or neurologic deficits.

SOAP Note:

Subjective: Patient reports a throbbing headache localized to the right temple, associated with nausea but no vomiting. Episodes last 4–6 hours.
Objective: BP 130/85, normal cranial nerve exam, no papilledema on fundoscopic exam.
Assessment: Likely migraine without aura.
Plan: Prescribe sumatriptan (50 mg at onset), recommend hydration, and advise avoiding known triggers. Follow up in 4 weeks if no improvement.

11. SOAP Notes Example for Sports Injury

Instructions:

Assess the mechanism of injury and current functional limitations. Include findings like swelling, tenderness, or instability in the joint.

SOAP Note:

Subjective: Patient reports right knee pain after twisting during soccer practice. Pain is worse with weight-bearing.
Objective: Swelling in the right knee, tenderness over the medial joint line, positive McMurray’s test.
Assessment: Suspected meniscal tear.
Plan: Order MRI to confirm diagnosis, recommend RICE (rest, ice, compression, elevation), and prescribe NSAIDs. Refer to orthopedics if necessary.

12. SOAP Notes Example for Dermatitis

Instructions:

Focus on the location, pattern, and triggers of the rash. Include any new exposures to allergens or irritants.

SOAP Note:

Subjective: Patient complains of an itchy rash on forearms after gardening. Reports recent contact with poison ivy.
Objective: Erythematous patches with vesicles and mild edema on both forearms.
Assessment: Allergic contact dermatitis.
Plan: Prescribe topical corticosteroid (hydrocortisone 1%), advise avoidance of irritants, and recommend oral antihistamine for itching.

13. SOAP Note for Obesity Counseling

Instructions:

Include lifestyle factors, diet, and exercise habits. Document BMI and any comorbid conditions related to obesity.

SOAP Note:

Subjective: Patient reports overeating during stressful periods and difficulty maintaining an exercise routine.
Objective: BMI 32, BP 130/85. No acute complaints.
Assessment: Obesity likely due to emotional eating and sedentary lifestyle.
Plan: Refer to dietitian, recommend aerobic exercise 30 minutes daily, and suggest behavioral therapy for stress management.

14. SOAP Notes Example for Infectious Mononucleosis

Instructions:

Record systemic symptoms like fever, fatigue, and lymphadenopathy. Include a detailed throat and abdominal exam.

SOAP Note:

Subjective: Patient reports extreme fatigue, sore throat, and swollen glands for one week.
Objective: Temp 100.5°F, cervical lymphadenopathy, mild splenomegaly, erythematous pharynx without exudate.
Assessment: Suspected infectious mononucleosis.
Plan: Order Monospot test, recommend rest and hydration, and advise against contact sports for 4–6 weeks.

15. SOAP Notes Example for Prenatal Visit

Instructions:

Focus on routine monitoring, including maternal weight, blood pressure, and fetal well-being. Note any new pregnancy-related complaints.

SOAP Note:

Subjective: Patient reports mild nausea but no vomiting or other complaints.
Objective: BP 110/70, fetal heart tones 150 bpm, fundal height consistent with gestational age.
Assessment: Normal prenatal checkup.
Plan: Continue prenatal vitamins, advise dietary adjustments for nausea, and schedule follow-up in 4 weeks.

16. SOAP Notes Example for Insomnia

Instructions:

Evaluate sleep habits, stressors, and other contributing factors like caffeine or alcohol use. Rule out secondary causes of sleep disruption.

SOAP Note:

Subjective: Patient reports difficulty falling asleep for the past 3 months, averaging 4 hours of sleep per night.
Objective: Normal physical exam, Epworth Sleepiness Scale: 12.
Assessment: Chronic insomnia likely due to stress.
Plan: Recommend sleep hygiene practices, trial of melatonin (3 mg nightly), and consider CBT-I for persistent symptoms.

17. SOAP Notes Example for COPD Exacerbation

Instructions:

Document changes in baseline symptoms like increased dyspnea or sputum production. Include respiratory status and oxygen saturation.

SOAP Note:

Subjective: Patient reports worsening shortness of breath and increased productive cough over the past three days.
Objective: SpO2 88% on room air, diffuse wheezing on auscultation, RR 22.
Assessment: Acute COPD exacerbation.
Plan: Prescribe prednisone (40 mg daily x 5 days), antibiotics (amoxicillin-clavulanate), and nebulized bronchodilators. Advise smoking cessation if applicable.

18. SOAP Notes Example for Anemia

Instructions:

Focus on symptoms like fatigue and pallor. Include lab findings (e.g., CBC, iron studies) and potential dietary causes.

SOAP Note:

Subjective: Patient complains of fatigue and occasional dizziness, denies bleeding or changes in diet.
Objective: Hb 10.2 g/dL, MCV 70 fL, ferritin low.
Assessment: Iron-deficiency anemia.
Plan: Prescribe oral iron supplements, recommend vitamin C to enhance absorption, and follow up in 6 weeks for repeat labs.

19. SOAP Notes Example for Ear Infection

Instructions:

Include symptoms like pain, hearing loss, or discharge. Document otoscopic findings for diagnosis.

SOAP Note:

Subjective: Patient reports ear pain and decreased hearing on the left side for three days.
Objective: Left tympanic membrane bulging and erythematous. No external drainage.
Assessment: Acute otitis media.
Plan: Prescribe amoxicillin (500 mg BID x 7 days) and analgesics for pain relief. Follow up if symptoms worsen.

20. SOAP Notes Example for Postpartum Depression

Instructions:

Screen using validated tools like PHQ-9 and document impacts on mother-child bonding and daily functioning.

SOAP Note:

Subjective: Patient reports sadness, irritability, and trouble bonding with her baby, 4 weeks postpartum.
Objective: PHQ-9 score: 16 (moderate depression).
Assessment: Postpartum depression.
Plan: Initiate counseling, consider low-dose SSRI (e.g., sertraline 25 mg), and schedule follow-up in 2 weeks.

21. SOAP Notes Example for Allergic Rhinitis

Instructions:

Document triggers (e.g., pollen, dust), seasonal patterns, and associated symptoms like sneezing, nasal congestion, and watery eyes.

SOAP Note:

Subjective: Patient reports frequent sneezing, nasal congestion, and itchy eyes, especially in the morning. Symptoms are worse during spring.
Objective: Nasal turbinates swollen and pale, clear nasal discharge, no sinus tenderness.
Assessment: Seasonal allergic rhinitis.
Plan: Prescribe intranasal corticosteroid spray (fluticasone), recommend antihistamines (loratadine), and encourage allergen avoidance measures.

22. SOAP Notes Example for Sciatica

Instructions:

Assess for lower back pain radiating down the leg, with associated neurological symptoms like numbness or weakness. Document findings from neurological and musculoskeletal exams.

SOAP Note:

Subjective: Patient complains of shooting pain radiating from the lower back to the left leg, worsened by sitting and bending.
Objective: Positive straight-leg raise on the left side, decreased left ankle reflex, no muscle atrophy.
Assessment: Sciatica, likely due to lumbar disc herniation.
Plan: Prescribe NSAIDs (naproxen), recommend physical therapy, and consider MRI if no improvement in 4 weeks.

23. SOAP Notes Example for Gout Flare

Instructions:

Capture the acute onset, joint involvement (e.g., redness, swelling), and history of gout or hyperuricemia. Document objective findings specific to the affected joint.

SOAP Note:

Subjective: Patient reports severe pain and swelling in the right big toe, onset 2 days ago. Denies trauma or fever.
Objective: Right first metatarsophalangeal joint swollen, erythematous, and tender to touch. No other joint involvement.
Assessment: Acute gout flare.
Plan: Prescribe colchicine (1.2 mg followed by 0.6 mg after 1 hour), advise low-purine diet, and monitor uric acid levels.

24. SOAP Notes Example for ADHD (Attention-Deficit/Hyperactivity Disorder)

Instructions:

Include behavioral symptoms (e.g., inattention, hyperactivity) and their impact on academic, social, or occupational functioning. Use validated scales if possible.

SOAP Note:

Subjective: Patient’s parent reports difficulty focusing in school, frequent interruptions during conversations, and hyperactivity at home. Symptoms have been present for over 6 months.
Objective: Vanderbilt ADHD Parent Rating Scale indicates moderate-to-severe inattention and hyperactivity. Normal physical exam.
Assessment: ADHD, combined type.
Plan: Start methylphenidate (5 mg BID), discuss behavioral therapy, and schedule follow-up in 1 month to monitor progress.

25. SOAP Notes Example for Acute Sinusitis

Instructions:

Focus on symptoms like facial pain, nasal congestion, and fever. Differentiate bacterial from viral causes based on symptom duration and severity.

SOAP Note:

Subjective: Patient reports facial pressure, purulent nasal discharge, and nasal congestion for 10 days. Worsening symptoms in the past 48 hours.
Objective: Tenderness over maxillary sinuses, purulent discharge visible in nasal passages. Temp 99.8°F.
Assessment: Acute bacterial sinusitis.
Plan: Prescribe amoxicillin-clavulanate (875 mg BID x 10 days), saline nasal spray, and advise hydration. Follow up if symptoms persist or worsen.

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FAQs on SOAP Notes Examples for Clinicians in the USA

1. What are SOAP notes, and why are they important?

SOAP notes are a standardized way to document patient interactions. They ensure your notes are clear, organized, and legally sound. For clinicians, they’re invaluable for tracking patient progress, sharing information with colleagues, and guiding treatment decisions.

2. How do I make the “Subjective” section meaningful?

Keep it patient-focused. Include the patient’s primary concern, their own words when possible, and relevant history. Think of this section as capturing the patient’s story.
Example: If a patient says, “I’ve had a pounding headache for two days, and it’s getting worse,” write that instead of summarizing it as “headache worsening.”

3. What’s the biggest mistake to avoid in the “Objective” section?

Avoid making subjective judgments here—stick to measurable facts. For example, instead of saying, “Patient looks sick,” describe what you observe: “Patient appears pale and is clutching their abdomen.” Always include vital signs and exam findings.

4. How do I structure the “Assessment” if I’m not 100% sure of the diagnosis?

It’s okay not to have a definitive diagnosis. Use a differential diagnosis approach, listing the most likely condition first. Add supporting evidence for each possibility.
Example:

Primary Diagnosis: Gastroenteritis.
Differential Diagnoses: Food poisoning, irritable bowel syndrome.

5. How detailed should the “Plan” section be?

The plan should cover immediate treatment, follow-ups, and patient education. Be clear and actionable.
Example:

Prescribe amoxicillin 500 mg BID for 10 days.
Advise rest and hydration.
Follow up in 2 weeks to reassess.

6. Can I use abbreviations in SOAP notes?

Yes, but only use common and universally understood abbreviations (e.g., BP for blood pressure, HR for heart rate). Avoid ambiguous or overly niche abbreviations to prevent confusion.

7. How long should a SOAP note be?

It depends on the complexity of the case. For routine visits, keep it concise (a few paragraphs). For more complex cases, your SOAP note may need extra detail, especially in the assessment and plan.

8. How do I balance clarity with medical-legal considerations?

Be factual and thorough, but avoid excessive details or speculative statements. If it’s not relevant to the patient’s care, it probably doesn’t need to be included. Write as though another clinician will need to act on your note.

9. What’s the best way to document a follow-up visit in SOAP format?

Highlight changes since the last visit.

Subjective: What’s improved or worsened?
Objective: New findings (e.g., test results or exam changes).
Assessment: Progress toward diagnosis or goals.
Plan: Adjustments based on progress or new findings.

10. How do SOAP notes fit into modern EHR systems?

Most EHRs already have SOAP templates. Use these to your advantage, but don’t let the format stifle your narrative. Remember, the patient’s story is more important than rigidly filling boxes.

11. Should I include patient non-compliance in my SOAP note?

Yes, but frame it respectfully and factually.
Example: Instead of writing, “Patient didn’t follow diet recommendations,” say, “Patient reports difficulty adhering to recommended low-sodium diet due to work stress.”

12. How do I write SOAP notes for pediatric patients?

Include input from caregivers and focus on observations. For example, a parent might report symptoms the child cannot articulate. Add developmental milestones or delays if relevant.

13. What’s the best way to document chronic conditions in SOAP notes?

For chronic conditions, emphasize changes since the last visit.
Example for diabetes follow-up:

Subjective: Patient reports no recent hypoglycemia.
Objective: HbA1c 6.9%, weight stable.
Assessment: Well-controlled diabetes.
Plan: Continue current medications, recheck HbA1c in 3 months.

14. Can SOAP notes be used for mental health patients?

Absolutely. For mental health cases, the subjective section often takes center stage since the patient’s narrative is critical. Be descriptive but concise, and include validated scales when appropriate (e.g., PHQ-9 for depression).
Example:

Subjective: “I’ve been feeling anxious every day, especially in the mornings.”
Objective: PHQ-9 score: 14.
Assessment: Generalized anxiety disorder.
Plan: Start CBT, prescribe sertraline 25 mg daily, follow up in 4 weeks.

15. What if I make a mistake in a SOAP note?

Mistakes happen. In paper records, draw a single line through the error, initial it, and write the correction. In EHRs, use the system’s correction or addendum feature. Never alter notes in a way that appears deceptive.

Final Thought: SOAP Notes Are a Skill Worth Mastering

SOAP notes are more than a documentation tool—they’re a window into your clinical reasoning and a guide for patient care. If you focus on being clear, factual, and patient-centered, you’ll not only meet professional standards but also improve communication with your team and ensure better outcomes for your patients.

Still have questions? Keep refining your skills—great SOAP notes come with practice!