SOAP Notes: Format, Template, Examples, and How to Write Them

SOAP notes are a structured way for healthcare professionals to document patient encounters. SOAP stands for Subjective, Objective, Assessment, and Plan.

A good SOAP note connects what the patient reports, what the clinician observes, what the findings mean, and what should happen next.

This guide explains the SOAP note format and includes copyable templates, examples, common mistakes, and guidance for reviewing AI-generated SOAP notes.

What Are SOAP Notes?

SOAP notes are clinical records divided into four sections:

• Subjective: What the patient or caregiver reports
• Objective: What the clinician observes, measures, or performs
• Assessment: What the findings mean
• Plan: What happens next

Clinicians use SOAP notes to document care, track progress, communicate with other providers, and explain the reasoning behind clinical decisions. A SOAP note may be used for an evaluation, follow-up visit, therapy session, consultation, or other clinical encounter.

What Does SOAP Stand For in Medical Notes?

Subjective

The Subjective section contains information reported by the patient, caregiver, or another relevant person. It may include:

• Primary complaint
• Symptoms
• Pain level
• Changes since the previous visit
• Functional limitations
• Relevant history
• Patient goals
• Response to treatment
• Adherence to recommendations or a home program

Statements from someone other than the patient should be attributed clearly.

Example:

The patient’s daughter reports that he has required more assistance with dressing during the past week.

Objective

The Objective section contains findings the clinician directly observes, measures, tests, or performs. It may include:

• Vital signs
• Range of motion
• Strength testing
• Gait findings
• Examination results
• Standardized outcome scores
• Mental-status observations
• Interventions performed
• Assistance or cueing required
• Patient response during treatment

Only include findings that affect the assessment, treatment decision, diagnosis, safety, or demonstration of progress.

Assessment

The Assessment section explains what the subjective and objective findings mean. It may include:

• Clinical interpretation
• Progress or regression
• Response to treatment
• Remaining impairments
• Factors limiting improvement
• Continued need for care
• Clinical impression
• Relationship to treatment goals

The Assessment should not simply repeat the previous sections. It should show the clinician’s reasoning.

Plan

The Plan section describes the next steps in care. It may include:

• Treatment progression
• Changes to the care plan
• Follow-up timing
• Referrals
• Tests or imaging
• Home instructions
• Precautions
• Frequency and duration of care
• Discharge planning

The Plan should follow logically from the Assessment.

SOAP Note Format

A strong SOAP note tells one connected clinical story: the patient reports a problem, the clinician identifies relevant findings, the findings are interpreted, and the plan responds to that interpretation.

The patient reports a problem, the clinician identifies relevant findings, the findings are interpreted, and the plan responds to that interpretation.

Example:

• Subjective: The patient reports increased knee pain when descending stairs.
• Objective: The patient demonstrates reduced quadriceps strength and poor eccentric control during step-down testing.
• Assessment: Weakness and impaired control are likely contributing to stair-related pain.
• Plan: Progress quadriceps strengthening and step-down training while monitoring symptoms.

Each section should support the next.

SOAP Note Template

Basic SOAP Note Template

Subjective

• Primary concern:
• Symptoms:
• Changes since the previous visit:
• Functional limitations:
• Patient-reported response:
• Relevant updates:
• Patient goals:

Objective

• Examination findings:
• Measurable results:
• Interventions performed:
• Assistance or cueing:
• Response during the encounter:
• Safety concerns:

Assessment

• Interpretation of findings:
• Progress toward goals:
• Response to treatment:
• Factors affecting progress:
• Continued need for care:

Plan

• Next treatment steps:
• Home recommendations:
• Referrals or tests:
• Follow-up:
• Frequency and duration:
• Precautions:

Short SOAP Note Template

• S: Patient-reported symptoms, function, changes, and response since the previous encounter.
• O: Relevant measurements, observations, interventions, and response during the encounter.
• A: Clinical interpretation, progress, remaining problems, and continued need for care.
• P: Next intervention, follow-up, home instructions, and treatment progression.

Detailed SOAP Note Template

Subjective

• Chief concern:
• Onset and duration:
• Symptom severity:
• Aggravating and relieving factors:
• Functional impact:
• Relevant changes:
• Adherence:
• Patient or caregiver goals:

Objective

• Vital signs:
• Examination findings:
• Functional testing:
• Outcome measures:
• Interventions completed:
• Dosage, duration, or intensity:
• Assistance and cueing:
• Response to intervention:
• Precautions:

Assessment

• Summary of findings:
• Comparison with previous status:
• Progress toward goals:
• Clinical significance:
• Barriers to recovery:
• Need for continued care:
• Prognosis or clinical impression:

Plan

• Planned intervention:
• Progression or modification:
• Home program:
• Patient education:
• Coordination with other providers:
• Referral or testing:
• Follow-up interval:
• Frequency and duration:

SOAP Note Example

The following SOAP note example shows how the four sections connect.

Subjective

The patient reports that right knee pain has decreased from 6/10 to 3/10 during the past two weeks. She can now walk for approximately 20 minutes before pain begins but continues to have difficulty descending stairs. She completed her home exercise program four times during the past week.

Objective

Right knee flexion measured 128 degrees, compared with 122 degrees at the previous visit. Right quadriceps strength was 4-/5. During a six-inch step-down, the patient demonstrated reduced eccentric control and mild dynamic knee valgus. She completed three sets of eight supported step-downs and three sets of ten sit-to-stands. Verbal cueing was required to maintain knee alignment. Pain remained at or below 3/10 throughout the session.

Assessment

The patient demonstrates improved knee range of motion and walking tolerance but continues to have quadriceps weakness and impaired eccentric control during stair descent. She tolerated progressed closed-chain strengthening without increased symptoms. Continued skilled physical therapy is appropriate to improve stair function and movement control.

Plan

Continue physical therapy twice weekly. Progress step-down height and resistance as tolerated. Reinforce knee alignment during closed-chain exercises. Continue the current home exercise program and add supported step-downs, two sets of eight once daily.

Physical Therapy SOAP Note Example

Subjective

The patient reports lower back pain of 4/10 this morning, compared with 6/10 at the previous visit. Sitting tolerance has improved from 20 minutes to approximately 40 minutes. She continues to experience stiffness after prolonged driving.

Objective

Lumbar flexion reached mid-shin with mild discomfort. Hip abduction strength measured 4-/5 bilaterally. The patient completed bridges, side-lying hip abduction, and repeated lumbar extension exercises. She required moderate verbal cueing to maintain trunk control during bridges. Symptoms decreased to 2/10 following repeated extension.

Assessment

The patient demonstrates improving symptom irritability and sitting tolerance. Persistent hip weakness and reduced trunk control may continue to contribute to difficulty with prolonged sitting. Her reduction in symptoms following repeated extension supports continued use of extension-based exercises.

Plan

Progress trunk and hip strengthening as tolerated. Continue repeated extension exercises in the home program. Reassess sitting tolerance and lumbar range of motion at the next visit.

Mental Health SOAP Note Example

Subjective

The client reports increased anxiety related to an upcoming job interview. She describes difficulty sleeping and repetitive thoughts about performing poorly. She used the breathing exercise discussed during the previous session on three occasions.

Objective

The client arrived on time and was appropriately dressed. Speech was clear and organized. Affect appeared anxious but appropriate to the content discussed. The client participated in cognitive restructuring and identified two recurring negative predictions related to the interview.

Assessment

The client continues to experience situational anxiety but demonstrates increased awareness of unhelpful thought patterns. She generated more balanced alternatives with moderate prompting. Current symptoms remain consistent with the treatment focus.

Plan

Continue cognitive restructuring and anxiety-management strategies. The client will complete a thought record before the next session and practice paced breathing once daily.

Occupational Therapy SOAP Note Example

Subjective

The patient reports continued difficulty fastening buttons and opening food containers due to right-hand weakness. She can now prepare a simple breakfast independently but requires additional time.

Objective

Right grip strength measured 18 pounds, compared with 14 pounds at the previous assessment. The patient completed buttoning, coin-manipulation, and container-opening tasks. She required minimal assistance with smaller buttons and no assistance with large buttons.

Assessment

The patient demonstrates improved grip strength and greater independence with basic meal preparation. Fine-motor coordination remains limited during tasks requiring precision. Continued occupational therapy is indicated to improve hand function and dressing independence.

Plan

Continue grip strengthening and fine-motor training. Add daily button-board practice to the home program. Progress to smaller fasteners as performance improves.

Nursing SOAP Note Example

Subjective

The patient reports nausea beginning this morning and rates abdominal discomfort at 3/10. She denies vomiting, chest pain, or shortness of breath.

Objective

Temperature was 37.1°C, heart rate 88 beats per minute, respiratory rate 16 breaths per minute, and blood pressure 124/78 mmHg. The abdomen was soft with mild epigastric tenderness. No guarding was observed. The patient tolerated small sips of water.

Assessment

The patient has mild nausea and epigastric discomfort without current signs of acute distress. Vital signs remain stable.

Plan

Encourage oral fluids as tolerated. Monitor symptoms and vital signs. Notify the attending clinician if pain increases, vomiting develops, or the patient becomes unable to tolerate fluids.

SOAP Note Examples: Weak vs Strong

Subjective

Weak: Patient feels better.

Strong: The patient reports that shoulder pain has decreased from 7/10 to 4/10 and that she can now reach the second kitchen shelf without assistance.

Objective

Weak: Patient did exercises and tolerated them well.

Strong: The patient completed three sets of ten resisted shoulder external-rotation exercises without increased pain and required verbal cueing to avoid trunk rotation.

Assessment

Weak: Patient is improving.

Strong: The patient demonstrates improved active shoulder elevation and reduced pain during reaching, but persistent rotator-cuff weakness continues to limit overhead lifting.

Plan

Weak: Continue treatment.

Strong: Continue therapy twice weekly and progress resisted overhead activity as tolerated. Reassess lifting capacity at the next visit.

How to Write SOAP Notes

• 1. Review the purpose of the encounter: Identify why the patient was seen and what needed to be evaluated, treated, or monitored. For follow-up visits, review the previous Assessment and Plan so the current note addresses what changed.
• 2. Record the patient’s relevant report: Document symptoms, function, progress, concerns, and relevant changes. Avoid recording every detail of the conversation; focus on information that affects care.
• 3. Document relevant objective findings: Include findings that support the assessment or influence decisions. Use precise measurements when available and record interventions, assistance, cueing, and patient response when relevant.
• 4. Explain what the findings mean: The Assessment should answer whether the patient is improving, what remains limited, contributing factors, response to treatment, and whether continued care is appropriate.
• 5. Connect the Plan to the Assessment: The next steps should address the problems identified in the Assessment.
• 6. Remove repetition and irrelevant details: Do not repeat the same information across multiple sections unless it serves a clear purpose.
• 7. Review the note before signing: Check for incorrect measurements, contradictory statements, wrong laterality, outdated copied text, missing clinical reasoning, and plans or interventions that were not discussed or performed.

Common SOAP Note Mistakes

• Repeating the same information: The Assessment should interpret the Subjective and Objective sections, not restate them.
• Mixing observations with interpretations: Direct findings belong in Objective; their meaning belongs in Assessment.
• Using vague language: Phrases such as 'doing well,' 'tolerated treatment,' and 'continue current plan' provide little value without supporting detail.
• Copying the same Assessment across visits: Update the Assessment to reflect current progress, barriers, and treatment response.
• Documenting an intervention without its purpose: Where relevant, connect the intervention to the impairment or goal being addressed.
• Failing to show functional progress: A measurement is more useful when connected to function.
• Including too much irrelevant information: Excessive history, copied text, and unrelated conversation can make important information harder to find.
• Writing a Plan that does not match the Assessment: The Plan should respond to the remaining problems identified in the Assessment.
• Signing an unreviewed AI-generated note: AI-generated documentation may omit important information, add irrelevant details, or state findings that were never observed. The clinician remains responsible for the final note.

How Long Should a SOAP Note Be?

There is no universal word count for a SOAP note. The appropriate length depends on several factors:

• Complexity
• Type of encounter
• Number of problems addressed
• Specialty
• Clinical risk
• Organizational requirements
• Payer requirements

A routine follow-up note may be short. An initial evaluation or complex encounter may require more detail. The goal is to document the clinically relevant encounter clearly without unnecessary repetition.

SOAP Notes vs Progress Notes

A progress note describes the purpose of the documentation: recording the patient’s status and care over time. A SOAP note describes the structure used to organize that documentation. A progress note may therefore be written in SOAP format. Other progress-note formats include DAP, BIRP, GIRP, and narrative documentation.

SOAP Notes vs DAP, BIRP, and GIRP Notes

SOAP Notes

SOAP stands for Subjective, Objective, Assessment, and Plan. It is widely used across medical, rehabilitation, and behavioral-health settings.

DAP Notes

DAP stands for Data, Assessment, and Plan. The Data section combines subjective and objective information.

BIRP Notes

BIRP stands for Behavior, Intervention, Response, and Plan. It is often used in behavioral-health documentation.

GIRP Notes

GIRP stands for Goal, Intervention, Response, and Plan. It emphasizes the treatment goal and the patient’s response to intervention.

Can AI Write SOAP Notes?

AI tools can create draft SOAP notes from clinical conversations, dictation, or entered information.

Depending on the tool, AI may capture the encounter, organize information into SOAP sections, apply a preferred template, generate a draft Assessment and Plan, extract symptoms or findings, reduce manual typing, and transfer text into an electronic health record.

AI-generated SOAP notes still require clinician review.

Potential errors include:

• Incorrect measurements
• Wrong laterality
• Misattributed statements
• Irrelevant conversation
• Missing findings
• Invented interventions
• Generic clinical reasoning
• Plans that were never discussed

AI should support documentation, not replace clinical judgment.

How to Review an AI-Generated SOAP Note

Before approving an AI-generated note, check the following:

• Are patient statements attributed correctly?
• Are symptoms, measurements, and timelines accurate?
• Is laterality correct?
• Were all listed examinations and interventions actually performed?
• Did the system invent any findings?
• Does the Assessment reflect the clinician’s reasoning?
• Does the Plan match what was discussed?
• Is irrelevant conversation included?
• Is unnecessary sensitive information present?
• Does the note accurately show progress?
• Would another clinician understand what occurred?
• Is the clinician comfortable signing it?

Frequently Asked Questions About SOAP Notes

• What are SOAP notes? — SOAP notes are clinical records organized into Subjective, Objective, Assessment, and Plan sections.
• What does SOAP stand for? — Subjective, Objective, Assessment, and Plan.
• What is the SOAP note format? — The SOAP note format starts with the patient’s report, followed by observable findings, clinical interpretation, and the next steps.
• How do you write SOAP notes? — Record relevant patient-reported information in Subjective, measurable findings in Objective, clinical interpretation in Assessment, and next steps in Plan.
• What goes in the Assessment section of a SOAP note? — The clinician’s interpretation of the encounter, including progress, remaining impairments, response to treatment, barriers, and continued need for care.
• What is an example of a SOAP note? — A SOAP note may document that a patient reports reduced knee pain, demonstrates improved range of motion but persistent weakness, is progressing but still limited on stairs, and will continue strengthening with graded progression.
• How long should a SOAP note be? — Long enough to document the clinically relevant encounter clearly; length depends on complexity, specialty, risk, and documentation requirements.
• Are SOAP notes the same as progress notes? — A SOAP note is a format that may be used for a progress note. 'Progress note' describes the purpose of the record, while 'SOAP' describes its structure.
• Can physical therapists use SOAP notes? — Yes. Physical therapists use SOAP notes to document symptoms, findings, interventions, progress, and treatment plans.
• Can AI create SOAP notes? — Yes. AI can generate draft SOAP notes, but clinicians should verify the content for accuracy, relevance, and consistency before signing.