This SOAP note template was created by a nurse practitioner to capture detailed SOAP notes, particularly 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
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 briefly discuss the importance of SOAP notes, its evolution, how to write them using templates with examples, and featured SOAP note templates you can use to help make note-taking easier.
Why is a Good Template for SOAP Notes Important?
A well-structured SOAP note template is critical not only for supporting clinical decision-making and facilitating multidisciplinary collaboration, but also for saving time and reducing errors.
For example, this psychiatric SOAP note template ensures all standard elements (e.g. mental status examination, E/M coding, etc.) are covered while minimizing charting time, allowing providers to 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 HIPAA (Health Insurance Portability and Accountability Act) and other medical record-keeping regulations. A good template enhances legal protection by ensuring you include all essential details in your notes.
Origins and Development of SOAP Note Templates
Renowned physician, Dr. Lawrence L. Weed, 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 record, “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 records 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 by integrating AI (artificial intelligence) and automation. From voice-to-text dictation to AI-assisted documentation, AI software like Heidi helps health workers worldwide to reduce 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 recorded 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:
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 sensitivity to light but notes that these headaches are different in nature, mostly feeling fatigued but no 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 (38°C), and fatigue.
Objective: Temperature 38°C, 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
Writing clear and well-structured SOAP notes is 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 the Help of Heidi
With the help of Heidi, the AI-powered medical scribe, you can streamline your workflow by generating personalized SOAP notes in seconds. This reduces your mental load, enabling you to focus more on patient care and less on paperwork. Here’s how Heidi works:
Transcribe - Press start the beginning of the session and Heidi captures every salient detail
Customize - Pick your preferred template and watch as Heidi writes your perfect note
Transform - Ask Heidi to create anything you need next - letters, suggesting billing codes or writing a patient summary
Heidi is HIPAA-compliant and ISO-certified, among other data privacy and security standards and regulations. Clinicians around the world trust Heidi to support over 1 million patient consultations every week.
This mental health SOAP note template utilizes the psychodynamic or object relations approach for documenting therapy sessions. It is designed by a psychologist to help capture the nuances of patient behavior, emotional states, and cognitive processes.
This physical therapy SOAP note template is built by a physiotherapist to easily document patient progress in an outpatient setting. It allows for hassle-free monitoring of patient adherence to home exercise programs, medication usage, and any new symptoms.
This family medicine SOAP note template is created by a family medicine specialist to comprehensively document initial patient visits. It helps ensure a holistic approach to patient care, supporting the formulation of a thorough assessment and plan.
This primary care SOAP note template is designed to help nurse practitioners efficiently document patient visits by providing a structured approach to record symptoms, assess conditions, and develop treatment plans.
This SOAP note template helps acupuncturists document client visits by easily capturing subjective symptoms, objective findings, and treatment plans in detail, including acupuncture points and other methods like cupping.
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.
How do you practice writing SOAP notes?
To practice writing SOAP notes effectively, familiarize yourself with the structure of Subjective, Objective, Assessment, and Plan, as well as what each section includes. Feel free to study examples in your field, then document patient encounters promptly using clear and concise language. Remember to review and refine your notes regularly, focusing on relevance. Using templates also helps build confidence and accuracy.
Is there an editable SOAP note template?
Yes, there are editable SOAP note templates using Heidi, the AI medical scribe for all clinicians. Simply browse through our template community, published by various specialists across the globe, and create an account to edit them based on your specific needs. Here is a short video of how a US-based healthcare provider customizes his Heidi templates.
How do you create a SOAP note template?
Creating a SOAP note template with Heidi is only a few clicks away. Other than importing pre-built templates from the community, users can upload a sample note with their preferred format and automatically convert it into an editable, AI-enabled SOAP note template within Heidi. Pro users can create unlimited custom templates and have unlimited access to Ask Heidi, our healthcare-specific AI chatbot designed to assist with streamlining workflows. See pricing.
