SOAP Note Template
This SOAP note template was created by a nurse practitioner to produce detailed SOAP notes, especially for complex cases or when multiple issues are raised during 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, etc.)
- Use AI to auto-generate SOAP notes according to the template structure
What is a SOAP Note Template?
A SOAP note template is a tool used by healthcare providers to systematically and efficiently document patient encounters. The SOAP acronym stands for Subjective, Objective, Assessment, and Plan. Following this format ensures your notes are clear and concise, helping you lessen the time and cognitive load involved in completing clinical documentation.
In this article, we’ll cover the importance of SOAP notes, their evolution, how to write them using templates with examples, and featured templates you can use right away.
Why is a Good Template for SOAP Notes Important?
A well-structured SOAP note template does more than tick a documentation box. It supports clinical decision-making, keeps teams aligned and reduces the kind of small errors that create big problems down the line.
For example, this psychiatric SOAP note template ensures all standard elements (e.g., mental status examination, E/M coding) are covered while minimizing charting time, so that providers can focus more on patient care.
SOAP notes also serve as robust legal documentation in case of audits, malpractice claims, or insurance disputes, by complying with the Health Insurance Portability and Accountability Act (HIPAA) and other medical recordkeeping regulations. A good template protects you in legal matters by ensuring you include all essential details in your notes.
Origins and Development of SOAP Note Templates
Dr. Lawrence L. Weed, a renowned physician, is most widely recognized 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, patient documentation was often disorganized and inconsistent, making it difficult to track progress and support clinical reasoning. For instance, a physician might write, “Patient is doing better,” without specifying what was better, how it was measured, or what the next steps were. The SOAP format helped make structured documentation the norm in healthcare settings.
Eventually, paper-based medical documents were largely phased out due to being inefficient, hard to access, prone to mistakes, and challenging to analyze. 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 have evolved to reduce administrative burden through AI and automation. From voice-to-text dictation to AI-assisted documentation, AI software like Heidi helps clinicians cut daily documentation time by an average of 50%.
For example, in just 14 weeks of using Heidi, Priority Physicians, leading providers of concierge medicine, decreased charting time by 70% and recovered $16,000 in lost clinical time. Dr. Shelagh Fraser shares, “Previously, I would spend 2-2.5 hours writing notes for a full day of seeing patients. Now with Heidi, I’ve got that down to around 40 minutes.”
How to Write SOAP Notes with Examples
By breaking down medical documentation into four key sections (Subjective, Objective, Assessment, and Plan), SOAP notes improve clarity, organization, and continuity of care. Here are general guidelines for writing each section, along with real-world examples to illustrate best practices:
Subjective
The Subjective section includes information provided by the patient, or in some cases, their caregiver, describing symptoms, medical history, and other health concerns. It is the patient's narrative and may contain:
- Chief Complaint: The main reason for the visit, revolving around the patient’s experience and often documented in their own words.
- History of Present Illness (HPI): A detailed description of symptoms, including onset, duration, location, severity, characteristics, aggravating and relieving factors, management of symptoms, response to treatment, and recent changes to condition.
- Past Medical History (PMH): Any relevant medical, surgical, and psychiatric history, including medications and herbal supplements.
- Family History: Any conditions in the family that may impact the patient's health.
- Social History: Any related lifestyle factors like smoking, alcohol use, and drug use.
- Review of Systems: A systematic checklist of symptoms affecting different body systems beyond the chief complaint.
Objective
The Objective section consists of measurable, observable, and verifiable data collected from a physical exam, laboratory tests, and imaging studies. This section is clinician-driven rather than patient-reported and may encompass:
- Vital Signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
- General Appearance: Patient's level of distress, consciousness, and hygiene.
- Physical Examination Findings: Organized by body systems such as neurological, cardiovascular, respiratory, musculoskeletal, etc.
- Diagnostic Tests and Imaging: Relevant lab results, X-rays, MRIs, ECGs, etc. if available
Assessment
The Assessment section is the healthcare provider’s analysis and interpretation of the subjective and objective entries, synthesizing them to arrive at a working diagnosis. It usually indicates:
- Primary Diagnosis: The most likely cause of the patient’s symptoms.
- Differential Diagnoses (DDx): Other possible conditions to consider.
- Justification: The clinical reasoning behind the diagnosis, often supported by guidelines or literature.
Plan
The Plan section outlines the next steps for treatment, patient education, and follow-up. It should be clear, actionable, and evidence-based, generally covering:
- Medications and Dosages: A list of prescribed medications, including their dosages, frequency, duration, and any adjustments to existing medications.
- Lifestyle Modifications: Any non-pharmacological recommendations aimed at improving the patient’s condition primarily through behavior, diet, or activity changes.
- Diagnostic Tests and Imaging: Ordered to confirm a diagnosis, rule out differential diagnoses, or monitor disease progression, if necessary.
- Follow-up Recommendations: Instructions on when the patient should return for reassessment, criteria for escalation, or referrals to specialists, if necessary.
SOAP Note Example for Physicians
Subjective
Chief Complaint: “Severe headache for 3 days.”
HPI: The patient, a 45-year-old female, presents with persistent headaches for the past week, starting in the morning and worsening throughout the day with a severity of 8/10 in the last 3 days. She reports a history of migraines with a throbbing sensation and photosensitivity, but notes that these headaches are different in nature, predominantly fatigued without nausea. She has tried over-the-counter pain relief with minimal effect, currently managing symptoms by using cold compresses. She denies recent changes in medication or lifestyle.
PMH: Hypertension and a cholecystectomy performed five years ago. Current medications include Lisinopril 10 mg daily and Ibuprofen as needed for pain. She has no known allergies.
Social History: The patient is a non-smoker, consumes alcohol occasionally, and works in a high-stress finance job.
Review of Systems:
- General: Reports fatigue and weight loss of 10 pounds over the last month.
- Head: Reports headache.
- Eyes: No vision changes reported.
- Neurological: Reports occasional tingling in the fingers.
Objective
Vital Signs:
- Blood Pressure: 130/90 mmHg
- Heart Rate: 78 bpm
- Respiratory Rate: 16 breaths/min
- Temperature: 98.6°F
- Oxygen Saturation: 98% on room air
General Appearance: Alert and oriented, appears fatigued.
Physical Examination Findings:
- HEENT: Mild tenderness on palpation of the temples, no sinus tenderness.
- Neurological: Cranial nerves II-XII intact, no focal deficits.
Assessment
Primary Diagnosis: Tension-type headache
DDx:
- Migraine – Less likely as no aura, nausea, or photophobia.
- Hypertension-related headache – Possible but BP only mildly elevated.
- Sinusitis – No nasal congestion or sinus tenderness.
Justification: The patient’s headache pattern (gradual onset, associated with stress, slightly relieved with over-the-counter analgesics) is consistent with a primary headache disorder. The lack of neurological deficits or concerning history (trauma, infection, sudden onset) makes secondary causes unlikely. The pain location (bilateral temples) and absence of nausea or photophobia lower the likelihood of migraine. Given the high-stress occupation and recent increased workload, the most probable diagnosis is a tension headache.
Plan
- Continue Lisinopril 10 mg daily and initiate trial of Naproxen 500 mg as an alternative to Ibuprofen for better long-term management.
- Recommend stress management techniques such as meditation and deep breathing exercises and encourage hydration, dietary adjustments, and regular sleep schedule
- Consider MRI of the brain with and without contrast to rule out intracranial pathology (new-onset headache different from past migraines, weight loss, occasional tingling).
- Instruct the patient to follow up in 2 weeks and contact the clinic if headaches worsen or neurological deficits develop (vision changes, severe tingling, or weakness).
SOAP Note Example for Medical Students
- Subjective: 25-year-old female reports a 3-day history of sore throat, mild fever (100.4°F), and fatigue.
- Objective: Temperature 100.4°F, throat erythema, mild cervical lymphadenopathy, no respiratory distress.
- Assessment: Acute pharyngitis, likely viral.
- Plan: Recommend supportive care with fluids, rest, and analgesics. Advise return if symptoms worsen or persist beyond 7 days.
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 and well-structured SOAP notes are essential for accurate documentation, effective patient care, and seamless communication among healthcare teams. However, manual note-taking can be time-consuming and prone to inconsistencies, especially in busy clinical settings, contributing to clinician burnout.
Easily Create SOAP Notes with Heidi
With Heidi, your AI care partner, you can streamline your workflow by generating personalized SOAP notes in seconds. This reduces your cognitive load, so you can focus on the patient rather than the paperwork behind you. Here’s how Heidi works:
- Transcribe - Press start at the beginning of the session and Heidi logs every clinical detail that matters
- Customize - Pick your preferred template and watch as Heidi writes your perfect note
- Transform - Ask Heidi to create anything you need next: referral letters, billing code suggestions, patient summaries, and more
Heidi is HIPAA-compliant and SOC 2-certified, with additional data privacy and security certifications available on request. Clinicians trust Heidi to support over 1 million patient visits every week.
Free SOAP Note Templates
FAQs about SOAP Note Templates
SOAP notes should include 4 sections: Subjective (patient’s symptoms and medical history), Objective (vital signs, physical exam, test results), Assessment (diagnosis and possible conditions based on findings), and Plan (treatment, further tests, and follow-up). This structured format helps ensure clear and efficient patient documentation.