SOAP Note Template & Examples
A free, ready-to-use SOAP template with real-world examples. SOAP — Subjective, Objective, Assessment, Plan — is the most widely used structure for clinical notes.
The four parts
Understanding SOAP notes
Each section answers a different question, so anyone reading the note can follow your thinking.
SSubjective
What the patient tells you: symptoms, concerns and history.
- Chief Complaint: 'I've been having chest pain for 2 days'
- History of Present Illness: Pain started suddenly, 7/10 severity, radiates to left arm
- Review of Systems: Denies shortness of breath, nausea, or dizziness
OObjective
What you observe and measure: vitals, exam and results.
- Vital Signs: BP 140/90, HR 88, RR 16, Temp 98.6°F, O2 Sat 98%
- Physical Exam: Alert, oriented x3, no acute distress
- Cardiovascular: Regular rate and rhythm, no murmurs
AAssessment
Your clinical impression and differential diagnosis.
- Primary Diagnosis: Chest pain, likely musculoskeletal (ICD-10: R07.89)
- Differential Diagnosis: Rule out acute coronary syndrome
- Risk Stratification: Low risk for acute cardiac event
PPlan
Treatment, follow-up and what the patient should do next.
- Medications: Continue current medications, add ibuprofen 400mg TID PRN
- Diagnostic: EKG completed (normal), consider stress test if symptoms persist
- Follow-up: Return in 1 week if symptoms persist, sooner if worsening
Copy or download
Complete SOAP note template
Copy it into your EHR or notes app, or download the PDF to print.
SOAP note template
SOAP NOTE TEMPLATE SUBJECTIVE: - Chief Complaint: [Patient's main concern in their own words] - History of Present Illness: [Detailed description of current symptoms] - Review of Systems: [Relevant positive/negative findings] - Past Medical History: [Relevant medical history] - Medications: [Current medications and dosages] - Allergies: [Known allergies and reactions] - Social History: [Relevant social factors] OBJECTIVE: - Vital Signs: BP ___ HR ___ RR ___ Temp ___ O2 Sat ___ - General Appearance: [Overall patient presentation] - Physical Examination: • HEENT: [Head, eyes, ears, nose, throat findings] • Cardiovascular: [Heart examination findings] • Respiratory: [Lung examination findings] • Abdomen: [Abdominal examination findings] • Neurological: [Neurological examination findings] - Diagnostic Results: [Lab results, imaging, etc.] ASSESSMENT: - Primary Diagnosis: [Main diagnosis with ICD-10 code] - Differential Diagnosis: [Alternative diagnoses considered] - Secondary Diagnoses: [Additional relevant diagnoses] - Clinical Impression: [Overall clinical assessment] PLAN: - Medications: [Prescribed medications with dosages] - Diagnostic Tests: [Ordered tests or procedures] - Patient Education: [Information provided to patient] - Follow-up: [Next appointment or monitoring plan] - Referrals: [Specialist referrals if needed] - Return Precautions: [When to seek immediate care]
Worked examples
SOAP note examples by specialty
Primary care
Subjective
45-year-old male presents with 3-day history of productive cough and fever. Reports fatigue and decreased appetite. No recent travel or sick contacts.
Objective
Vital signs: T 101.2°F, BP 128/82, HR 92, RR 18, O2 Sat 96%. Physical exam reveals crackles in right lower lobe, otherwise unremarkable.
Assessment
Community-acquired pneumonia, right lower lobe (ICD-10: J18.9)
Plan
Azithromycin 500mg daily x 5 days, supportive care, return if worsening, chest X-ray in 6 weeks to confirm resolution.
Mental health
Subjective
28-year-old female reports increased anxiety and panic attacks over past 2 weeks. Difficulty sleeping, racing thoughts. Denies suicidal ideation.
Objective
Alert, cooperative, anxious affect. Speech rapid, thought process organized. No psychotic symptoms. PHQ-9 score: 12, GAD-7 score: 15.
Assessment
Generalized anxiety disorder with panic attacks (ICD-10: F41.1)
Plan
Start sertraline 25mg daily, CBT referral, relaxation techniques, follow-up in 2 weeks to assess medication tolerance.
Pediatrics
Subjective
6-year-old brought by mother for ear pain x 2 days. Child reports pain 8/10, difficulty hearing. No fever reported at home.
Objective
Vital signs stable. Right tympanic membrane erythematous and bulging. Left ear normal. No lymphadenopathy.
Assessment
Acute otitis media, right ear (ICD-10: H66.91)
Plan
Amoxicillin 400mg/5ml, 1 tsp BID x 10 days. Pain management with acetaminophen. Return if no improvement in 48-72 hours.
Best practices
Writing SOAP notes that hold up
Do
- Use objective, professional language
- Include specific measurements and observations
- Quote the patient's exact words when it matters
- Use standard medical abbreviations
- Include ICD-10 codes for diagnoses
Avoid
- Subjective language in the Objective section
- Personal opinions or judgments
- Non-standard abbreviations
- Leaving sections blank without explanation
- Copying and pasting without reviewing
Skip the typing. Keep the SOAP.
ReasonNotes listens to the visit and writes a complete SOAP note for you — ready to review about a minute after you finish.
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