SOAP note template, with a complete example
Used by: Physicians, NPs, PAs and other clinicians, for outpatient and follow-up visits.
SOAP stands for Subjective, Objective, Assessment and Plan. It is the most common structure for a visit note because it follows the order of clinical reasoning: what the patient tells you, what you find, what you think, and what you will do.
Below is a section-by-section template you can copy, followed by a complete example written for an invented patient.
The template, section by section
Subjective
The patient’s account: the chief complaint in their words, the history of present illness, and the pertinent review of systems, medications and history.
- Chief complaint
- HPI: onset, location, duration, character, aggravating and relieving factors, timing, severity
- Pertinent ROS
- Current medications and allergies
- Relevant past, family and social history
Objective
What you measure and observe: vital signs, the examination, and results reviewed at the visit.
- Vital signs
- Focused examination by system
- Labs, imaging and other results reviewed
Assessment
Your clinical judgment: the diagnosis or differential for each problem, with the reasoning that connects the subjective and objective findings.
- Problem or diagnosis, with status (new, stable, worsening)
- Differential where the diagnosis is not settled
- Key reasoning
Plan
What happens next for each problem: tests, treatment, education, referrals and follow-up.
- Diagnostics ordered
- Treatment and medication changes
- Patient education and shared decisions
- Referrals
- Follow-up interval and return precautions
SOAP note example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Subjective
CC: "My knee has been hurting for three weeks."
HPI: 54-year-old with right knee pain for 3 weeks, gradual onset, medial, worse with stairs and after walking more than 20 minutes, better with rest. Morning stiffness under 15 minutes. No injury, locking, giving way, fever or swelling of other joints. Tried acetaminophen with partial relief.
ROS: Negative for fever, weight loss, rash, calf pain.
Medications: Lisinopril 10 mg daily. Acetaminophen as needed. Allergies: none known.
Objective
BP 132/84, HR 72, BMI 31.
Right knee: no effusion or warmth, medial joint line tenderness, crepitus with flexion, full extension, flexion to 120 degrees, stable to varus and valgus stress, negative McMurray. Left knee normal.
Assessment
1. Right knee pain, most consistent with medial compartment osteoarthritis given age, mechanical pattern, brief morning stiffness and crepitus. No red flags for infection or inflammatory arthritis.
2. Hypertension, at goal on current therapy.
Plan
1. Knee: weight-bearing knee X-rays. Start topical diclofenac to the right knee up to four times daily. Physical therapy referral for quadriceps strengthening. Discussed weight loss as the most effective long-term measure. Return sooner for swelling, fever, locking or inability to bear weight.
2. Hypertension: continue lisinopril. Recheck BMP at the next visit.
Follow-up in 6 weeks.
Tips from practice
- Write the assessment as reasoning, not a restated problem list. A reader should see why you landed where you did.
- Number the assessment and plan by problem so each plan item clearly belongs to a diagnosis.
- Document return precautions; they matter clinically and for the record.
- Specific diagnoses (laterality, acuity, type) support specific ICD-10 codes.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
14-day Pro trial, no credit card required. Everything in Pro, including Rounding, for up to 150 notes. To keep Pro after day 14, subscribe for $79/month plus applicable tax. If you don't, nothing is charged and your account becomes read-only, with every note kept.
Questions
- What does SOAP stand for?
- Subjective, Objective, Assessment and Plan.
- What is the difference between a SOAP note and a progress note?
- A progress note is any note documenting an ongoing course of care; SOAP is one structure for writing it. Many outpatient and inpatient progress notes are written in SOAP format.
- Can an AI scribe write a SOAP note?
- Yes. Scribeable writes SOAP notes from a recorded or dictated visit, suggests ICD-10 codes for the assessment, and links each sentence drawn from the visit back to where it came from.
Reviewed 2026-11-08.