If you trained in medicine, you wrote your first SOAP note before you ever wrote a prescription. The format has outlived EMR migrations, billing overhauls, and three generations of dictation software — because it maps cleanly to how clinicians actually think: hear the story, gather the data, form the impression, decide what’s next.
This page gives you a complete SOAP note example you can copy and adapt, a blank template to keep on hand, and a quick breakdown of what belongs in each section. If you want the why behind each section, pair it with our step-by-step guide to writing a SOAP note. At the end, a note on how to get the first draft written for you so the format stops eating your evening.
What “SOAP” stands for
SOAP is an acronym for the four sections of a clinical progress note: Subjective, Objective, Assessment, Plan. It came out of the problem-oriented medical record developed by Dr. Lawrence Weed in the 1960s, and it stuck because it forces a logical sequence — what the patient tells you, what you measure, what you conclude, and what you’ll do about it.
| Section | What goes here | Source |
|---|---|---|
| Subjective | The patient’s story in their words — chief complaint, HPI, relevant history, symptoms | Patient / caregiver |
| Objective | Measurable, observable data — vitals, exam findings, labs, imaging | You and the chart |
| Assessment | Your clinical impression — diagnosis or differential, problem list, clinical reasoning | Your judgment |
| Plan | What happens next — treatment, orders, referrals, patient education, follow-up | Your decision |
A complete SOAP note example
Here is a full SOAP note for a routine primary-care follow-up — a 54-year-old patient with type 2 diabetes and hypertension. The detail level is typical of a real progress note: enough to support the assessment, billing, and the next visit, without padding.
Patient: 54 y/o male | Date: 06/21/2026 | Encounter: Chronic disease follow-up
S — Subjective
Chief complaint: “Here for my diabetes check-up.” 54-year-old male with a 6-year history of type 2 diabetes and essential hypertension presents for routine follow-up. Reports good adherence to metformin 1000 mg BID and lisinopril 20 mg daily. Home glucose log shows fasting readings of 130–160 mg/dL over the past two weeks. Denies polyuria, polydipsia, blurred vision, chest pain, dyspnea, or lower-extremity numbness or tingling. Walking 20–30 minutes most days; reports difficulty cutting back on evening snacks. No medication side effects, no hypoglycemic episodes. No new complaints.
O — Objective
- Vitals: BP 138/84, HR 76, T 36.7 °C, RR 14, SpO₂ 98% RA. Weight 92 kg (BMI 30.1, up 1.5 kg from last visit).
- General: Well-appearing, in no acute distress.
- CV: Regular rate and rhythm, no murmurs, rubs, or gallops. No peripheral edema.
- Resp: Clear to auscultation bilaterally.
- Extremities/Feet: Monofilament testing intact bilaterally. No ulcers, no skin breakdown. Pedal pulses 2+.
- Labs (drawn this visit, prior results): HbA1c 7.6% (was 7.2% three months ago). LDL 88 mg/dL. eGFR 78. Urine albumin-to-creatinine ratio 18 mg/g.
A — Assessment
- Type 2 diabetes mellitus, suboptimally controlled — HbA1c up to 7.6% from 7.2%, likely driven by recent dietary changes and modest weight gain. No evidence of neuropathy, nephropathy, or retinopathy at this time.
- Essential hypertension — Borderline at 138/84 on current therapy; not yet at goal of <130/80 for a patient with diabetes.
- Overweight/obesity (BMI 30.1) — Trending up, contributing to #1 and #2.
P — Plan
- Diabetes: Continue metformin 1000 mg BID. Reinforce dietary counseling, focused on evening snacking; referral placed to diabetes educator/dietitian. Recheck HbA1c in 3 months. Discussed adding a second agent (SGLT2 inhibitor) if A1c remains above goal at next visit, given cardiovascular and renal benefit.
- Hypertension: Increase lisinopril to 40 mg daily. Patient to log home BP twice weekly. Recheck in 4 weeks.
- Weight: Goal of 3–5% weight loss over 3 months. Reviewed activity and portion strategies.
- Preventive: Annual dilated eye exam ordered. Foot exam completed today, normal. Flu vaccine administered.
- Follow-up: Return in 4 weeks for BP recheck; 3 months for diabetes labs. Patient verbalized understanding and agreement with the plan.
Notice what each section does and doesn’t carry. The Subjective is the patient’s narrative, including the pertinent negatives that justify not chasing other problems. The Objective is only measurable data — no interpretation. The Assessment is where your reasoning lives, tying findings to a problem list. The Plan is specific and actionable, one numbered item per problem, with concrete follow-up.
Blank SOAP note template
Keep this on hand and fill it in per encounter:
S — SUBJECTIVE
Chief complaint:
HPI (onset, location, duration, character, aggravating/relieving, timing, severity):
Relevant PMH / meds / allergies:
Pertinent positives and negatives (ROS):
O — OBJECTIVE
Vitals:
Physical exam (by system):
Labs / imaging / point-of-care results:
A — ASSESSMENT
Problem 1 — diagnosis + brief reasoning:
Problem 2 — ...
Differential (if undifferentiated):
P — PLAN
Problem 1 — treatment, orders, education, follow-up:
Problem 2 — ...
Return precautions / next visit:A shorter acute-visit example
SOAP scales down for a focused, single-problem visit. Same structure, far less text:
S: 28 y/o female, 3 days of sore throat, fever to 38.4 °C, painful swallowing. No cough, no rhinorrhea. Sick contact at home. O: T 38.2 °C, BP 118/72. Tonsillar exudate bilaterally, tender anterior cervical lymphadenopathy. No cough. Centor score 4. Rapid strep positive. A: Acute streptococcal pharyngitis. P: Amoxicillin 500 mg BID × 10 days. Supportive care, fluids, analgesia. Return if worsening dysphagia, drooling, or difficulty breathing. Follow up PRN.
SOAP notes across specialties and roles
The four sections stay the same, but emphasis shifts with the setting. A family medicine or internal medicine SOAP note carries a longer problem list and chronic-disease tracking, like the diabetes example above. An emergency room or hospital SOAP note leans on the Objective and a tight, time-stamped Assessment and Plan — the streptococcal pharyngitis note is closer to that shape. A cardiology note weights the cardiovascular exam, ECG, and prior studies. Nurse practitioners, PAs, and medical students write to the same structure — the difference is scope of practice and supervision, not the format.
You’ll also encounter the APSO variant — the same content reordered as Assessment, Plan, Subjective, Objective — favored in some hospital and specialty settings so the reader sees the clinical impression first. Whatever the specialty, the blank SOAP note template above works as a starting point: copy it into Word, Google Docs, or your EMR, save it, and adapt the headers to your visit type.
The mistakes that make notes take longer than the visit
- Putting interpretation in Objective. “Patient appears diabetic” is an assessment, not an observation. Keep O strictly to measurable data.
- A vague Plan. “Continue current management” tells the next clinician — and the auditor — nothing. Be specific: doses, intervals, what triggers a change.
- A Subjective that’s a transcript. You don’t need every word the patient said. You need the story that supports your assessment, including pertinent negatives.
- Copy-forward drift. Pulling yesterday’s note forward and not updating it is how stale, inaccurate charts happen. Each note should reflect this encounter.
- Writing it at 9 p.m. The single biggest issue isn’t structure — it’s that the note gets written hours after the visit, from memory, after a full clinic day.
Get the SOAP note drafted for you
The format isn’t the hard part. The hard part is that documentation is the last step of a long job — and by the time you sit down to write, you’re reconstructing the visit from memory at the end of a 10-hour day.
This is what Claire is built to take off your plate. Claire works like an AI senior resident: it runs the structured intake and gathers the history before you walk in, organizes the clinical data, and drafts the SOAP note in your format — so the Subjective, Objective, and a proposed Assessment and Plan are already assembled when you sit down. You review, edit, and sign. The judgment and the signature never leave you; the legwork does.
It’s EMR-agnostic and built for clinical settings end to end, with HIPAA, PHIPA, and PIPEDA handled — so the draft lands where you already chart.
See how Claire turns an encounter into a review-ready note — explore how Claire works, compare it on our AI scribe comparison hub, or book a demo.
Sources
- Weed LL. “Medical Records That Guide and Teach.” New England Journal of Medicine, 1968 — origin of the problem-oriented medical record and the SOAP structure.