SOAP Note Template
This SOAP note template, created by a nurse practitioner, provides detailed documentation for complex cases or when multiple issues come up in a single visit. With this template, you can easily:
- Document all four components of a SOAP note, including follow-up tasks like referrals and patient instructions
- Insert specific information when explicitly mentioned by the patient (e.g., past medical history, description of symptoms, review of systems)
- Automatically generate SOAP notes according to the template structure
What is a SOAP Note Template?
A SOAP note template is a tool that clinicians use to document patient encounters quickly and accurately. The SOAP acronym stands for Subjective, Objective, Assessment, and Plan. Following this format keeps your notes clear and concise, and reduces the time you spend on clinical documentation.
In this article, we’ll discuss why SOAP notes matter, how they evolved, how to write them with worked examples, and a set of ready-to-use templates.
Why is a Good Template for SOAP Notes Important?
A well-structured SOAP note template supports clinical decision-making, keeps your team aligned, and saves time by reducing errors. It works the same way whether you're charting in family medicine, allied health, mental health, or a hospital setting.
Good notes are also your best protection if care is ever questioned. Clear, legible records satisfy legal, professional, and ethical obligations and act as evidence if care is later questioned. Patients can bring a claim anywhere from 6 to 30 years after treatment, depending on the province.
That protection only holds if your documentation practices meet the right privacy standard too. Ontario runs on the Personal Health Information Protection Act (PHIPA), Alberta on the Health Information Act (HIA), and British Columbia and Quebec have their own provincial acts.
On a national level, the Personal Information Protection and Electronic Documents Act (PIPEDA) fills the gaps elsewhere. A good template helps your notes hold up no matter which rules apply.
Origins and Development of SOAP Note Templates
Dr. Lawrence L. Weed, a renowned physician, is most widely recognised as the inventor of the SOAP note. He also developed the first electronic medical record (EMR) in 1969, Problem-Oriented Medical Information System (PROMIS).
Before SOAP notes, documentation was often inconsistent. For example, a physician might write "Patient is doing better" with no indication of what improved, how it was measured, or what came next. The SOAP format turned structured documentation into the standard across healthcare.
Eventually, paper-based medical records were largely phased out due to being inefficient, hard to access, prone to mistakes, and challenging to analyse. With the rise of electronic health records (EHRs) in the late 1990s and early 2000s, digitizing SOAP notes became imperative. EHR systems began integrating templates to make SOAP notes more accessible across healthcare teams.
Today, SOAP note templates use AI and automation to cut the paperwork that follows clinicians home. From voice-to-text dictation to AI-assisted notes, Heidi helps clinicians cut daily documentation time by 66%.
Take Ottawa Institute of Cognitive Behavioural Therapy (OICBT), a leading Canadian mental health practice, as an example. Since adopting Heidi, they’ve cut clinician documentation time from 213 to 71 minutes per week. Dr. Pete Kelly, clinical psychologist and CFO at OICBT, shares that the tool is helping the team "focus on patient care instead of paperwork."
How to Write SOAP Notes with Examples
SOAP notes split medical documentation into four sections: Subjective, Objective, Assessment, and Plan. That structure keeps a note organized, easy to scan, and useful to the next clinician who opens the chart.
Below are guidelines for writing each section:
Subjective
The Subjective section holds what the patient, or in some cases their caregiver, tells you about their symptoms, history, and other health concerns. It is the patient's narrative, and typically includes:
- Chief Complaint: The main reason for the visit, centred on the patient's experience and often recorded in their own words.
- History of Present Illness: A detailed account of the symptom, covering onset, duration, location, severity, character, aggravating and relieving factors, what the patient has tried, how they responded to it, and any recent changes to the condition.
- Past Medical History: Relevant medical, surgical, and psychiatric history. Where this is held in a Cumulative Patient Profile or the electronic medical record, note "as per profile" rather than repeating it in full, provided the record is current.
- Current Medications: What the patient is taking now, including dose, frequency, and route.
- Allergies: Known drug allergies, or a note that none are known.
- Social History: Lifestyle factors such as smoking, alcohol use, drug use, and occupation.
- Review of Systems: A structured check of symptoms across body systems, beyond the chief complaint.
For visits covering more than one problem, number each problem in the Subjective section and carry that same number through the Objective, Assessment, and Plan entries that relate to it.
Objective
The Objective section holds measurable, observable data collected from the physical exam and any tests on hand. It is clinician-driven rather than patient-reported, and typically includes:
- Vitals: Blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
- On Examination: Findings from the physical exam, organized by body system, such as general appearance, head and neck, or neurological.
- Test Results: Any lab or imaging results available at the time of the visit.
Assessment
The Assessment section is your analysis of the subjective and objective findings, synthesized into a working diagnosis. It typically includes:
- Impression: Your overall read on what is going on, including any red flags that need to be ruled out.
- Differential Diagnosis: The range of possible conditions, ranked by likelihood, with brief reasoning for each.
Plan
The Plan section sets out the next steps for treatment, patient education, and follow-up. It should be clear and actionable, generally covering:
- Medications: Any medications started, stopped, or adjusted, including dose, frequency, and duration.
- Investigations: Tests or imaging ordered to confirm a diagnosis, rule out alternatives, or monitor progression.
- Conservative Management: Non-drug recommendations, such as lifestyle or behavioural changes.
- Patient Education: Key points discussed with the patient, and any handouts or resources provided.
- Follow-up: When the patient should return for reassessment.
- Red Flags and Safety Netting: Symptoms that should prompt the patient to seek urgent care, and what to do if they occur.
SOAP Note Example for Physicians
Subjective
Chief Complaint: Severe headache x 3 days.
HPI: 45-year-old female presents with a 1-week history of persistent, progressive headaches, worsening to a severity of 8/10 over the last 3 days. The pain typically starts in the morning and escalates throughout the day. Patient has a known history of migraines (usually throbbing with photophobia) but states this current headache feels entirely different. Associated with generalised fatigue. She denies nausea, vomiting, or visual disturbances. Has tried OTC ibuprofen with minimal relief; currently using cold compresses. No recent lifestyle or medication changes.
PMHx: Hypertension, Cholecystectomy (5 years ago).
Current Medications: Lisinopril 10 mg daily, Ibuprofen 400 mg PRN.
Allergies: NKDA.
Social History: Non-smoker. Occasional alcohol use. Works in a high-stress corporate finance role.
Review of Systems:
- General: Fatigue. Notes an unintentional weight loss of approximately 4.5 kg over the past month.
- Neuro: Reports occasional tingling in her fingers bilaterally. No focal weakness.
- HEENT: Negative for nasal congestion or rhinorrhea.
Objective
Vitals:
- Blood Pressure: 130/90 mmHg
- Heart Rate: 78 bpm
- Respiratory Rate: 16/min
- Temperature: 37.0 °C (Oral)
- Oxygen Saturation: 98% on room air
O/E (On Examination):
- General: Alert and oriented x3. Appears fatigued but is in no acute distress.
- HEENT: Mild tenderness to palpation over bilateral temples. No sinus or TMJ tenderness.
- Neuro: Cranial nerves II-XII grossly intact. Gait is normal. No focal neurological deficits demonstrated today.
Test Results:
- Routine Labs: CBC, TSH, electrolytes, and HbA1c all within normal limits.
Assessment
Impression: New-onset atypical headache, highly suspicious for tension-type headache secondary to occupational stress. Must rule out secondary intracranial pathology given red flags (age >40 at onset, weight loss, transient paraesthesia).
Differential Diagnosis:
- Tension-type headache: Most likely given bilateral temporal location, gradual diurnal worsening, and high stress levels.
- Migraine: Less likely; atypical presentation with no aura, nausea, or photophobia.
- Hypertension-related headache: Unlikely; blood pressure is only minimally elevated today.
- Sinusitis: Ruled out clinically by lack of sinus tenderness or congestion.
Plan
- Medications:
- Continue Lisinopril 10 mg daily for hypertension.
- Discontinue Ibuprofen. Initiate a trial of Naproxen 500 mg PO BID PRN (with food) for acute pain management.
- Investigations: Submit requisition for outpatient MRI Brain (with and without gadolinium contrast) to investigate red flags.
- Conservative Management: Counselled on stress optimisation strategies, strict hydration, dietary consistency, and regular sleep hygiene.
- Patient Education: Discussed the clinical distinction between her baseline migraines and this new headache pattern. Explained the physiological impact of chronic occupational stress and poor sleep hygiene on tension headaches. Provided a standard headache diary to track daily triggers and symptoms.
- Follow-up: Return to clinic in 2 weeks to review progress and monitor symptoms.
- Red Flags / Safety Netting: Patient counselled on red flag symptoms. Instructed to present to the nearest Emergency Department immediately if she experiences a sudden "thunderclap" worsening of pain, new visual changes, or focal neurological deficits (e.g., localised weakness or worsening paresthesia).
SOAP Note Example for Medical Students
Subjective
- HPI: 25 y/o F presents with a 3-day history of progressive odynophagia, fatigue, and subjective fevers.
- Pertinent Negatives: No cough, rhinorrhea, dyspnea, or dysphagia. Managing oral secretions well. No known sick contacts.
- PMHx: Nil.
- Meds: Acetaminophen PRN.
- Allergies: NKDA.
Objective
- Vitals: T 38.0°C (Oral) | HR 82 bpm | BP 116/74 mmHg | RR 14/min | SpO2 99% on RA
- O/E:
- Gen: Alert, well-appearing, NAD. Speaking in full sentences. No stridor.
- Pharynx: Erythema present. No tonsillar hypertrophy or exudates. Uvula midline. No trismus.
- Neck: Mild, tender anterior cervical lymphadenopathy. Posterior nodes clear.
- Test Results:
- Point-of-Care Rapid Strep Test (RADT): Negative.
Assessment
- Impression: Acute pharyngitis, likely viral.
- Clinical Reasoning: McIsaac Score = 3 (Age 15–44 [0], Fever [1], No cough [1], Ant. nodes [1], No exudates [0]). Probability of GABHS (Strep) is ~30%; warrants a throat swab per Canadian guidelines rather than empiric antibiotics.
- DDx: Viral pharyngitis (most likely), GABHS, early Infectious Mononucleosis.
Plan
- Investigations: Throat swab collected for bacterial culture today.
- Symptomatic Rx: Fluids, rest, salt-water gargles. Maximise Acetaminophen to 500–1000 mg PO q4-6h PRN (max 4 g/day) or Ibuprofen 400 mg PO q6h PRN for analgesia.
- Patient Education: Educated the patient that the vast majority of sore throats are viral and that antibiotics do not cure viral infections or speed up recovery. Explained that because her rapid strep test was negative, we will hold off on antibiotics to prevent unnecessary side effects and resistance, pending the final 48-hour culture results. Counselled on rigorous hand hygiene and avoiding sharing cups/utensils.
- Follow-up: Clinic to contact patient with swab results in 48 hours. Start antibiotics only if culture is positive. Otherwise, follow up if symptoms persist >7 days.
- Safety Netting: Counselled to present to the Emergency Department immediately if she develops difficulty breathing, drooling, inability to swallow liquids, or a muffled voice.
Medical Student Note — Reviewed with Dr. [Name]
SOAP Note Template PDF Download
You can download a copy of this document, or auto-fill it seamlessly with Heidi, your AI care partner.
Clear, well-structured SOAP notes support accurate documentation, better patient care and consistent communication across your care team. However, manual note-taking eats time and invites inconsistency. And when the day is full, that adds up to burnout.
Easily Create SOAP Notes with Heidi
The best part of your session is the conversation. Heidi handles everything after it.
Heidi transcribes the visit and turns it into a personalised SOAP note in seconds. That's less time charting after hours, and more attention for the person actually in the room. Here's what that gives you:
- Less time on documentation: Heidi builds a structured, editable note in seconds, so your attention stays on the patient, not the screen.
- Notes that match how you work: Choose your template and Heidi writes in your format, not a generic one you have to rework.
- A full clinical day, from one session: Referral letters, patient summaries, billing suggestions: Heidi generates them all from the same visit so nothing gets re-created from scratch.
Canadian clinicians trust Heidi with over 620,000 patient visits every week. Heidi meets PIPEDA and applicable provincial health privacy law, so your patient information is handled to the standard the work demands.