20+ SOAP Note Examples for Every Medical Specialty (2025 Guide)

Quick Answer: SOAP Note Examples

SOAP notes follow a structured format with four sections: Subjective (patient-reported symptoms), Objective (measurable clinical data), Assessment (clinical diagnosis), and Plan (treatment strategy). This standardized documentation method is used by physicians, nurses, therapists, and other healthcare professionals to create clear, legally compliant medical records.

Whether you’re documenting a primary care visit, mental health session, or specialty consultation, proper SOAP notes ensure quality patient care, meet regulatory requirements, and reduce documentation time by up to 70% with modern AI tools.

What Are SOAP Notes?

SOAP notes represent the gold standard for medical documentation across healthcare settings. First introduced in the 1960s by Dr. Lawrence Weed, this format organizes patient information into four distinct sections that guide clinical reasoning and interdisciplinary communication.

The acronym SOAP stands for:

Subjective: Information reported by the patient
Objective: Measurable, observable clinical data
Assessment: Professional medical judgment and diagnosis
Plan: Treatment strategy and follow-up

Healthcare professionals including physicians, nurse practitioners, physician assistants, therapists, pharmacists, and social workers use SOAP notes to maintain consistent documentation standards. While not legally mandated, SOAP notes help meet HIPAA compliance and provide defensible records during audits or legal challenges.

Complete SOAP Note Structure Explained

Subjective Section

The subjective section captures the patient’s perspective in their own words. This includes:

Chief complaint: “Patient reports sharp chest pain for 3 hours”
History of present illness: When symptoms began, severity, aggravating factors
Review of systems: Additional symptoms the patient mentions
Past medical history: Relevant previous conditions
Medications and allergies: Current prescriptions and known reactions
Social history: Lifestyle factors affecting health

Objective Section

The objective section contains factual, measurable data you directly observe or measure:

Vital signs: BP 130/85, HR 78, RR 16, Temp 98.6°F, O2 sat 98%
Physical examination findings: Heart sounds regular, lungs clear bilaterally
Lab results: CBC, metabolic panel, imaging reports
Patient appearance: Alert, oriented, no acute distress
Mental status: Mood, affect, cognitive function observations

Assessment Section

The assessment synthesizes subjective and objective data into clinical judgment:

Primary diagnosis: Acute gastroesophageal reflux disease (GERD)
Differential diagnoses: Rule out cardiac causes, peptic ulcer disease
Progress evaluation: Patient improving on current treatment plan
Severity rating: Mild, moderate, or severe presentation

Plan Section

The plan outlines next steps for patient care:

Medications: Start omeprazole 20mg daily before breakfast
Diagnostic tests: Order upper endoscopy if symptoms persist
Referrals: Gastroenterology consult in 2 weeks
Patient education: Avoid trigger foods, elevate head of bed
Follow-up: Return visit in 4 weeks or sooner if symptoms worsen

Primary Care SOAP Note Example

Patient: Sarah Johnson, 42-year-old female
Date: January 15, 2025
Chief Complaint: Persistent headaches for 2 weeks

Subjective

Patient reports daily headaches for 14 days, describing pain as “throbbing” and bilateral, rated 6/10 severity. Symptoms worse in afternoon, partially relieved with ibuprofen. Denies vision changes, nausea, or vomiting. Reports increased work stress due to recent project deadlines. Sleep pattern disrupted, averaging 5-6 hours nightly. No recent trauma or fever. Medical history includes hypertension controlled with lisinopril 10mg daily. No known drug allergies.

Objective

Vitals: BP 138/88, HR 76, RR 14, Temp 98.4°F, Weight 165 lbs
General: Alert, oriented x3, no acute distress
HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light. Extraocular movements intact. Fundoscopic exam normal, no papilledema
Neck: Supple, no lymphadenopathy, full range of motion
Neurological: Cranial nerves II-XII grossly intact. Normal gait, coordination, and reflexes

Assessment

1. Tension-type headache, likely stress-related
2. Hypertension, suboptimal control
3. Sleep deprivation contributing to symptoms

Plan

1. Headache management: Continue ibuprofen 400mg as needed, maximum 3 times daily
2. Add prophylaxis: Amitriptyline 10mg at bedtime
3. Lifestyle modifications: Stress management techniques, improve sleep hygiene
4. Hypertension: Increase lisinopril to 20mg daily
5. Follow-up: Return in 2 weeks to reassess headache frequency and blood pressure control
6. Red flags counseling: Return immediately for severe sudden headache, vision changes, or neurological symptoms

Mental Health SOAP Note Example

Client: Michael Torres, 28-year-old male
Session Date: January 15, 2025
Session Type: Individual psychotherapy (45 minutes)

Subjective

Client reports feeling “on edge” and “constantly worried” for past 3 weeks. Describes difficulty concentrating at work, mind racing with worst-case scenarios about job performance. Sleep onset latency increased to 60-90 minutes with frequent nighttime awakening. Appetite decreased, unintentional 5-pound weight loss. Denies suicidal ideation. States therapy has been “somewhat helpful” and uses deep breathing exercises learned in previous sessions. Reports medication compliance with escitalopram 10mg daily.

Objective

Appearance: Client arrived on time, casually dressed, adequate grooming
Behavior: Fidgety, frequent hand-wringing, difficulty maintaining eye contact
Speech: Rapid rate, increased volume when discussing work stress
Mood: “Anxious” (self-reported)
Affect: Anxious, somewhat restricted range
Thought Process: Linear and goal-directed, occasional tangentiality when anxious
Thought Content: Preoccupied with work performance concerns, no suicidal/homicidal ideation
Insight: Good – recognizes anxiety is disproportionate to actual job performance
Judgment: Fair – seeking help, using coping strategies

Assessment

F41.1 Generalized Anxiety Disorder (moderate severity)
Client’s anxiety symptoms have increased in severity over past 3 weeks, triggered by work-related stressors. Continues to meet criteria for GAD with persistent worry, physical tension, and sleep disruption. Positive response noted to CBT interventions and medication, though symptoms not fully controlled. No evidence of comorbid depression or substance use. Prognosis is good with continued therapy and possible medication adjustment.

Plan

1. Continue weekly individual psychotherapy using CBT approach
2. Focus next session on cognitive restructuring techniques for work-related catastrophic thinking
3. Assign homework: Daily thought record tracking worry patterns
4. Consulted with prescribing physician regarding possible escitalopram dose increase to 15mg
5. Encourage consistent use of relaxation techniques before bed
6. Schedule follow-up in 1 week to monitor symptom progression
7. Provided crisis resources and suicide prevention number for emergencies

Nurse Practitioner SOAP Note Example

Patient: Robert Chen, 58-year-old male
Date: January 15, 2025
Chief Complaint: Follow-up for Type 2 Diabetes management

Subjective

Patient presents for routine diabetes follow-up. Reports good adherence to metformin 1000mg twice daily and glipizide 5mg daily. Blood glucose readings at home range 110-145 mg/dL fasting. Denies polyuria, polydipsia, or polyphagia. Diet improved with reduced carbohydrate intake per dietitian recommendations. Walking 30 minutes 4-5 times weekly. Recent A1C result: 7.2% (down from 8.1% three months ago). Complains of occasional numbness in feet, describing “tingling sensation” at night. No chest pain, shortness of breath, or vision changes.

Objective

Vitals: BP 125/78, HR 72, BMI 29.5 (down from 31.2)
General: Well-appearing, no acute distress
Cardiovascular: Regular rate and rhythm, no murmurs
Respiratory: Lungs clear to auscultation bilaterally
Extremities: No edema. Pedal pulses 2+ bilaterally. Monofilament testing shows decreased sensation bilateral feet (4/10 sites positive)
Labs (fasting): Glucose 128 mg/dL, A1C 7.2%, Lipid panel: Total cholesterol 195, LDL 110, HDL 45, Triglycerides 200

Assessment

1. Type 2 Diabetes Mellitus with improving glycemic control (A1C 7.2%)
2. Peripheral neuropathy, diabetic, early stage
3. Dyslipidemia, borderline
4. Overweight (BMI 29.5), improving with lifestyle modifications

Plan

1. Diabetes: Continue current medication regimen (metformin 1000mg BID, glipizide 5mg daily). Target A1C <7.0%
2. Neuropathy: Start gabapentin 100mg at bedtime, may titrate up if needed. Educate on foot care and daily foot inspections
3. Dyslipidemia: Start atorvastatin 10mg daily. Recheck lipid panel in 6 weeks
4. Weight management: Continue current exercise and diet plan. Congratulated patient on 10-pound weight loss
5. Referrals: Schedule ophthalmology exam for diabetic retinopathy screening. Consider podiatry if neuropathy progresses
6. Follow-up: Return in 3 months with labs (A1C, basic metabolic panel, lipid panel) 1 week prior to visit

Physical Therapy SOAP Note Example

Patient: Jennifer Martinez, 34-year-old female
Date: January 15, 2025
Session: Visit 4 of 12 authorized sessions
Diagnosis: Right rotator cuff tendinitis

Subjective

Patient reports 40% improvement in shoulder pain since initial evaluation 2 weeks ago. Describes pain as “dull ache” at rest, rated 3/10, increasing to 6/10 with overhead activities. States she can now reach overhead to retrieve items from kitchen cabinets with minimal discomfort, which was previously impossible. Sleep improved – able to lie on right side for short periods. Compliance with home exercise program rated 8/10. Completed exercises 5 days this week. Returns to desk job with ergonomic modifications implemented.

Objective

Observation: Holds right shoulder in slightly elevated position
Active ROM (right shoulder):
– Flexion: 140° (was 110° at initial eval) – pain-free
– Abduction: 130° (was 100°) – mild pain at end range
– External rotation: 45° (was 30°) – pain-free
Strength testing (right shoulder):
– Flexion: 4/5 (was 3+/5)
– Abduction: 4/5 (was 3/5)
– External rotation: 4/5 (was 3+/5)
Special tests: Empty can test positive but improved, Hawkins-Kennedy test negative
Palpation: Mild tenderness over supraspinatus insertion

Assessment

Patient demonstrating excellent progress toward functional goals. ROM improvements of 30° flexion and abduction indicate reduced inflammation and improved tissue healing. Strength gains appropriate for this stage of rehabilitation. Pain reduction correlates with functional improvements in ADLs. Patient motivated and compliant with treatment plan. On track to meet discharge goals by visit 12.

Plan

Treatment performed today:
1. Therapeutic exercises: Scapular stabilization, rotator cuff strengthening with resistance band (3 sets x 15 reps)
2. Manual therapy: Soft tissue mobilization to periscapular muscles, grade III joint mobilizations
3. Modalities: Ice pack applied for 10 minutes post-treatment
4. Patient education: Proper posture at computer workstation, activity modification techniques
Home exercise program progression: Increased resistance band color, added wall slides
Next visit: Continue current interventions, reassess ROM and strength
Long-term goals: Full pain-free ROM, 5/5 strength all planes, return to recreational tennis by week 8

Common SOAP Note Mistakes to Avoid

1. Incomplete Subjective Information

Mistake: “Patient has headache.”
Correct: “Patient reports throbbing frontal headache for 3 days, rated 7/10 severity, worse in morning, partially relieved with ibuprofen.”

Always document onset, duration, severity, quality, aggravating/relieving factors, and associated symptoms.

2. Mixing Subjective and Objective Data

Mistake: Including “Patient appears anxious” in Subjective section
Correct: Patient self-reports “feeling anxious” (Subjective) vs. “Patient observed fidgeting, avoiding eye contact” (Objective)

3. Assessment Without Supporting Data

Mistake: “Patient has pneumonia” without documenting abnormal breath sounds, fever, or imaging
Correct: Link diagnosis to specific findings: “Right lower lobe pneumonia evidenced by fever 101.5°F, productive cough, crackles on auscultation, infiltrate on CXR”

4. Vague Treatment Plans

Mistake: “Patient to follow up as needed”
Correct: “Patient to return in 2 weeks for blood pressure recheck. Sooner if symptoms worsen or new concerns arise. Provided written return precautions.”

5. Documentation Inconsistencies

Ensure all four sections align logically. If you document chest pain in Subjective, your Objective section should include cardiac examination findings, Assessment should address cardiac differential diagnoses, and Plan should include appropriate cardiac workup.

SOAP Note Variations by Specialty

Emergency Medicine: Rapid SOAP Format

Emergency departments often use condensed SOAP notes focusing on:

Chief complaint and HPI
Critical vital signs and physical exam pertinent positives/negatives
Working diagnosis and rule-outs
Immediate interventions and disposition

Pediatrics: Family-Centered Documentation

Pediatric SOAP notes include:

Parent/caregiver report in Subjective
Growth parameters and developmental milestones in Objective
Age-appropriate assessment and anticipatory guidance in Plan

Surgery: Procedure-Focused SOAP

Surgical SOAP notes emphasize:

Pre-operative findings
Intra-operative course and complications
Post-operative recovery and wound healing
Surgical follow-up timeline

Can AI Write SOAP Notes?

Yes, modern AI medical scribes like ChatGPT and specialized healthcare documentation tools can generate SOAP notes from patient conversations. However, healthcare professionals must:

Review and edit all AI-generated content for accuracy
Verify clinical reasoning matches actual patient presentation
Add nuanced clinical judgment AI may miss
Ensure HIPAA compliance when using AI tools
Maintain professional liability – providers remain legally responsible for documentation

AI scribes excel at capturing patient conversations and structuring notes, but clinical assessment and treatment planning require human expertise and professional judgment.

Best Practices for Efficient SOAP Documentation

1. Use Templates Strategically

Create specialty-specific templates with common diagnoses, physical exam findings, and treatment plans. Customize for each patient rather than using completely from scratch.

2. Document in Real-Time

Complete notes immediately after patient encounters when details are fresh. This reduces errors and after-hours charting time.

3. Master Medical Abbreviations

Use approved medical abbreviations to speed documentation while maintaining clarity. Avoid ambiguous abbreviations on the Joint Commission’s “Do Not Use” list.

4. Focus on Pertinent Details

Document what’s clinically relevant rather than every possible finding. “Heart: RRR, no murmurs” suffices for routine exam in stable patient.

5. Use Technology Wisely

Voice-to-text tools, EHR templates, and AI documentation assistants can reduce charting time by 70% while improving note quality.

Transform Your Documentation Workflow

Writing comprehensive SOAP notes shouldn’t consume 2-3 hours of your evening. Physicians using modern AI-powered documentation tools report:

70% reduction in documentation time
Same-day note closure rates above 95%
Improved work-life balance by eliminating “pajama time”
Better patient interaction with less computer focus during visits

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Frequently Asked Questions

Do nurses still write SOAP notes?

Yes, nurses increasingly use SOAP notes, especially nurse practitioners and advanced practice nurses. While traditionally a physician documentation method, SOAP format supports clinical reasoning and interdisciplinary communication across all healthcare professionals.

Are SOAP notes legally required?

SOAP notes aren’t legally mandated but are widely accepted as best practice. They help meet legal and regulatory requirements including HIPAA compliance by ensuring thorough, organized records that can defend clinical decisions if audited or legally challenged.

How long should a SOAP note be?

SOAP note length varies by encounter complexity. Routine follow-ups may require 200-300 words, while complex new patient evaluations might need 800-1200 words. Focus on clinical relevance rather than arbitrary length requirements.

What’s the difference between SOAP and SOAPIE notes?

SOAPIE notes add two sections: Intervention (specific treatments performed) and Evaluation (patient response to interventions). Common in nursing and therapy documentation where ongoing treatment response matters.

Can medical students write SOAP notes?

Yes, medical students write SOAP notes as part of clinical training. Supervising physicians must review and co-sign student documentation before it becomes part of the official medical record.

Related Resources:

Medical Disclaimer: This article provides general information about SOAP note documentation. Always follow your institution’s specific documentation policies and applicable regulations. Consult with healthcare compliance professionals for guidance on your specific situation.