Medical SOAP Note Template

What Is a Medical SOAP Note?

The SOAP note is one of the most widely used documentation formats in medicine. Originally developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record, it divides clinical documentation into four distinct sections: Subjective, Objective, Assessment, and Plan. This structure forces logical thinking — you collect data before interpreting it, and you interpret before acting. Learn more about SOAP vs other clinical note formats.

While SOAP notes are used across healthcare disciplines, this template is tailored for physicians documenting medical encounters — office visits, hospital rounds, urgent care evaluations, and follow-up appointments.

Who Uses This Template?

• Primary care physicians for routine and acute visits
• Hospitalists for daily inpatient progress notes
• Emergency medicine physicians for ED evaluations
• Specialists for outpatient follow-ups
• Medical students and residents learning structured documentation

Template

Subjective (S)

The Subjective section captures everything the patient tells you. It is the patient's story in clinical language.

Chief Complaint (CC)

State the primary reason for the visit in one brief sentence, ideally using the patient's own words.

• Example: "Chest tightness for two days."
• Example: "Here for blood pressure follow-up."

History of Present Illness (HPI)

Develop the chief complaint into a clinical narrative. Include:

• Onset: "Began two days ago while climbing stairs."
• Quality: "Describes a pressure-like sensation across the anterior chest."
• Severity: "Rates 7/10 at worst, currently 3/10 at rest."
• Duration: "Episodes last 5–10 minutes."
• Aggravating factors: "Exertion, heavy meals."
• Relieving factors: "Rest, sitting upright."
• Associated symptoms: "Mild dyspnea with episodes. Denies diaphoresis, nausea, radiation to arm or jaw."

Full HPI example: "Mrs. Thompson is a 64-year-old woman with a history of hypertension and hyperlipidemia presenting with two days of intermittent chest tightness. Episodes occur with exertion — specifically climbing stairs and walking more than two blocks — and resolve within 5–10 minutes of rest. She rates the pressure at 7/10 during episodes, currently 3/10 at rest. She reports mild dyspnea during episodes but denies diaphoresis, nausea, palpitations, or radiation. No prior history of similar symptoms. She has not taken any new medications."

Review of Systems (ROS)

Document pertinent positives and negatives. For the example above:

• Cardiovascular: Positive for exertional chest tightness and dyspnea. Negative for palpitations, syncope, lower-extremity edema.
• Respiratory: Negative for cough, wheezing, hemoptysis.
• Gastrointestinal: Negative for heartburn, dysphagia.
• Constitutional: Negative for fever, weight loss, fatigue.

Past Medical, Surgical, Family, and Social History

• PMH: Hypertension (diagnosed 2018), hyperlipidemia. No diabetes.
• PSH: Cholecystectomy (2015).
• Medications: Lisinopril 20 mg daily, atorvastatin 40 mg daily.
• Allergies: Penicillin — rash.
• FH: Father with MI at age 59. Mother with hypertension.
• SH: Never smoker. Occasional alcohol (2–3 glasses of wine per week). Retired teacher. Lives with spouse.

Objective (O)

The Objective section contains measurable, observable data — your findings, not the patient's report.

Vital Signs

• BP: 148/92 mmHg (right arm, seated)
• HR: 82 bpm, regular
• RR: 16 breaths/min
• Temp: 98.4 F (oral)
• SpO2: 97% on room air
• BMI: 29.1

Physical Examination

• General: Alert, in no acute distress, well-nourished.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. PMI nondisplaced. No JVD. Peripheral pulses 2+ bilaterally.
• Respiratory: Clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. Symmetric chest expansion.
• Abdomen: Soft, nontender, nondistended. No organomegaly.
• Extremities: No edema, cyanosis, or clubbing.

Diagnostic Data

Include any labs, imaging, or test results available at the time of documentation.

• ECG: Normal sinus rhythm, no ST-segment changes, no T-wave inversions.
• CXR: No cardiomegaly, no infiltrates, no effusions.
• Troponin I: Pending at time of note.

Assessment (A)

Synthesize the Subjective and Objective data into your clinical interpretation. List each problem separately.

Problem 1: New-onset exertional chest tightness Differential includes stable angina, atypical GERD, and musculoskeletal chest wall pain. Clinical presentation — exertional onset, pressure quality, relief with rest — combined with cardiovascular risk factors (age, hypertension, hyperlipidemia, family history of premature CAD) places stable angina highest on the differential. ECG is reassuring but does not exclude ischemia. Troponin pending.

Problem 2: Hypertension, suboptimally controlled BP 148/92 today on lisinopril 20 mg. May require dose adjustment or addition of second agent, though will address after cardiac workup is complete.

Plan (P)

Write a specific, actionable plan for each problem in the Assessment.

Problem 1: Exertional chest tightness

• Serial troponins q6h x 2 to rule out acute coronary syndrome
• Stress echocardiogram within 48 hours if troponins negative
• Start aspirin 81 mg daily
• SL nitroglycerin 0.4 mg PRN for acute episodes; instruct on proper use
• Cardiology referral if stress test is abnormal
• Patient counseled on warning signs requiring emergency evaluation: rest pain lasting more than 15 minutes, radiation to jaw or arm, diaphoresis, syncope

Problem 2: Hypertension

• Continue lisinopril 20 mg daily; defer dose change until cardiac evaluation is complete
• Home BP monitoring: check and log AM and PM readings
• Reinforce dietary sodium reduction (goal less than 2,300 mg/day)
• Recheck BP at follow-up in two weeks

Follow-up: Return in two weeks for BP check and stress test results review. Sooner if symptoms escalate.

When to Use the SOAP Format

The SOAP format works best for:

• Outpatient office visits — Its brevity suits the pace of clinic
• Daily inpatient progress notes — Hospitalists use it to track day-to-day changes
• Urgent care encounters — Efficient structure for acute presentations
• Follow-up visits — Easy to compare one SOAP note to the next over time

For more complex documentation needs — initial H&Ps, operative notes, discharge summaries — other formats may be more appropriate. But for the daily clinical encounter, SOAP remains the gold standard.

Tips for Writing Better SOAP Notes

1. Keep the Subjective and Objective separate. Do not interpret in the Objective section. "Patient appears anxious" is objective. "Patient is anxious about her diagnosis" belongs in the Subjective.
2. Number your problems in the Assessment. This makes the Plan easier to organize and easier for the next reader to follow.
3. Be specific in the Plan. "Will treat" is not a plan. "Start amoxicillin 500 mg TID for 10 days" is a plan.
4. Include safety netting. Every Plan should tell the patient when to come back and what warning signs should prompt earlier return.
5. Avoid unnecessary negatives in the exam. Documenting a full neurological exam for an uncomplicated UTI adds length without value. Focus your exam on the relevant systems.

Automate Your SOAP Notes

Writing SOAP notes by hand or from memory at the end of a long clinic day leads to burnout and documentation errors. NotuDocs records your patient encounters and generates structured SOAP notes automatically, so you review and approve rather than reconstruct from memory. Less charting, more accurate records.