SOAP Note Example Library: Templates and Annotated Guides for Clinicians

By Rachel M, Registered Nurse, Master of Science in Nursing, with James O, Doctor of Physical Therapy. Clinically reviewed by Dr. Helen B, Doctor of Nursing Practice. Last reviewed 22 April 2026.

Why the SOAP format became the clinical documentation standard

The SOAP structure did not appear by accident. Physician Lawrence Weed introduced the problem-oriented medical record, known as the problem-oriented medical record or POMR, during the late 1960s to replace the narrative, source-ordered charts that made chronic-disease tracking almost impossible (Weed, 1968). Weed's reform organized every chart around an active problem list, and each problem received a structured note with four labelled sections. That structure is the Subjective, Objective, Assessment, and Plan template students still learn today (Weed, 1969).

Regulatory bodies amplified adoption. The Joint Commission's Sentinel Event Alert 58 identified communication breakdowns as a root cause in an estimated 80 percent of serious medical errors and recommended structured handoff formats, a category in which SOAP-style notes sit comfortably (Joint Commission Sentinel Event Alert 58, 2017). The Office of the National Coordinator for Health Information Technology embedded SOAP-style templates directly into certified electronic health record systems, reinforcing problem-oriented care across Medicare-funded settings (Office of the National Coordinator for Health Information Technology, 2022).

Professional bodies followed. The American Nurses Association includes SOAP-style structures inside its documentation principles, supporting continuity, accountability, and legal defensibility in nursing records (American Nurses Association, 2021). The American Physical Therapy Association requires SOAP-ordered progress notes for payer reimbursement, and the American Occupational Therapy Association incorporates SOAP inside its Occupational Therapy Practice Framework, 4th edition (American Physical Therapy Association Guidelines for Physical Therapy Documentation, 2019; American Occupational Therapy Association Occupational Therapy Practice Framework, 4th edition, 2020). A format that earned approval across medicine, nursing, physical therapy, and occupational therapy in the span of a generation is not going anywhere.

The four SOAP sections decoded

Every SOAP note template divides the encounter into four disciplined sections. Each section has a different information source, a different voice, and a different purpose. Mixing them is the most common student error.

Subjective: what the patient reports

The Subjective section captures the patient's own words. Chief complaint, history of present illness, review of systems, pain description using OPQRST, medication adherence, and social context all live here. Use quotation marks for the patient's exact phrasing when the wording carries clinical weight, for example "chest feels like an elephant sitting on it." In a mental health SOAP note, Subjective data expands to mood, sleep, appetite, suicidal ideation screening, and perceived stressors, all captured as the client describes them.

Objective: what the clinician observes and measures

The Objective section records measurable, reproducible findings. Vital signs, physical examination results, laboratory values, imaging, goniometry, manual muscle testing, and validated screening instrument scores, such as the Patient Health Questionnaire 9 or the Oswestry Disability Index, belong here. A PT SOAP note fills this section with range of motion in degrees, strength grades, and functional outcome measures. A physician assistant SOAP note layers in differential-focused exam findings.

Assessment: synthesizing clinical judgment

The Assessment section is where diagnostic reasoning appears on paper. Clinical reasoning in the Assessment section reflects diagnostic synthesis supported by evidence-based practice (Tanner, 2006). Students often copy labs into Assessment or repeat the complaint. Both are wrong. Assessment is interpretation: the differential, the working diagnosis with International Classification of Diseases, Tenth Revision coding where relevant, and short justification. For a recurring visit, note progress, regression, or stability against the prior plan.

Plan: SMART next steps

The Plan section answers "what happens next." Diagnostics ordered, medications prescribed or titrated, therapy frequency and duration, patient education topics, referrals, and follow-up interval all appear. SMART goal structure improves the measurability of the Plan component (Doran, 1981), meaning each goal should be Specific, Measurable, Achievable, Relevant, and Time-bound. "Patient will tolerate 30 minutes ambulation with rolling walker by week 4" is SMART. "Improve walking" is not.

How do you write a SOAP note in five steps

Turning a patient encounter into a defensible SOAP note example takes five disciplined steps. The order matters because each step feeds the next.

Step 1: Gather subjective data through structured interview

Start with an open prompt: "What brings you in today?" Then narrow with OPQRST for pain (Onset, Provocation, Quality, Radiation, Severity, Timing), SAMPLE for general history, and targeted review of systems. In mental health, add suicide and safety screening using the Columbia Protocol. Record direct quotations when the wording is clinically meaningful.

Step 2: Document objective findings with vitals, labs, and exam

Record vitals in a consistent order, then move head to toe. Add relevant laboratory and imaging results, validated instrument scores, and functional tests. Keep numeric precision. "Blood pressure elevated" is weaker evidence than "Blood pressure 162 over 98, repeat after five minutes 158 over 94."

Step 3: Formulate the assessment using differential reasoning

List the working diagnosis first, followed by two or three differentials. Justify each with the objective and subjective findings that support it. For chronic-disease follow-up, include whether the patient is controlled, worsening, or newly symptomatic.

Step 4: Build the plan with SMART goals and interventions

Translate the assessment into action. Split the plan into diagnostics, therapeutics, education, referrals, and follow-up. Each goal should meet the SMART goals test. Attach a time frame to every item, for example "recheck hemoglobin A1c in 90 days."

Step 5: Review, sign, and time-stamp for legal defensibility

Re-read the note with a reader's eye. Confirm every abbreviation is on your facility's approved list. Sign with full credentials. Time-stamp the entry. Late entries should be labelled as such. Interdisciplinary handoffs benefit from structured documentation formats that reduce communication errors (Joint Commission Sentinel Event Alert 58, 2017), and a signed, time-stamped note is the evidence that handoff happened.

SOAP note examples across disciplines

The same four letters serve different professions in different ways. Below are six annotated SOAP note example blocks, each matched to a discipline and scenario.

Nursing SOAP note example (annotated)

Scenario: 58-year-old female admitted for Type 2 diabetes education and blood glucose stabilization.

For a full nursing walkthrough including Nursing Diagnoses using the North American Nursing Diagnosis Association International taxonomy, see the Nursing SOAP notes deep dive.

Physical therapy SOAP note example (annotated)

Physical therapists use SOAP-structured progress notes for payer reimbursement and clinical reasoning (American Physical Therapy Association Guidelines for Physical Therapy Documentation, 2019). A sample progress note for a patient recovering from a total knee arthroplasty reads:

Occupational therapy SOAP note example (annotated)

Occupational therapy practice uses SOAP notes to capture client performance in daily occupations (American Occupational Therapy Association Occupational Therapy Practice Framework, 4th edition, 2020). Example for a stroke survivor working on upper-extremity dressing:

Physician assistant SOAP note example (annotated)

Physician assistants in primary care often write SOAP notes for acute visits. Scenario: 45-year-old male with chest pain.

Mental health SOAP note example (annotated)

Mental health clinicians adapt the SOAP framework for psychotherapy progress notes aligned with third-party payer requirements (Cameron and Turtle-Song, 2002). Example for a client with generalized anxiety disorder at session 6 of cognitive behavioral therapy:

Pediatric SOAP note example (annotated)

Pediatric encounters require growth parameters and developmental context. Full pediatric SOAP note template offers a fillable form; the annotated version appears alongside Denver Developmental Screening references. Headers must include caregiver identity, interpreter use, and immunization status alongside the standard four sections.

SOAP note examples by clinical condition

Formats alone do not write themselves. Below are condition-specific worked sketches, each linking to a deeper programmatic page for the full annotated walk-through.

SOAP note for Type 2 diabetes

Diabetes notes lean heavily on the Objective section: fingerstick blood glucose, hemoglobin A1c, lipid panel, foot exam, and microalbumin. Assessment must address control status (controlled, uncontrolled, newly diagnosed), complications screening, and comorbidity. Plan integrates medication titration, carbohydrate counting, and registered-dietitian referral. Full worked example and template: SOAP note for Type 2 diabetes.

SOAP note for hypertension

Hypertension follow-up notes anchor on blood pressure readings across visits, lifestyle factors (sodium, alcohol, exercise), and target organ damage screening. Plan includes guideline-based medication adjustment using the 2017 American College of Cardiology and American Heart Association thresholds. Deeper walk-through: SOAP note for hypertension.

SOAP note for chest pain with rule-out workup

Chest pain notes must document differential reasoning visibly: acute coronary syndrome, pulmonary embolism, aortic dissection, and musculoskeletal etiologies should appear in the Assessment. HEART score and Wells score belong in Objective. See the detailed SOAP note for chest pain example for a complete emergency-department annotated note.

SOAP note for chronic obstructive pulmonary disease exacerbation

For chronic obstructive pulmonary disease exacerbation, capture modified Medical Research Council dyspnea score and COPD Assessment Test score, forced expiratory volume in one second where available, and oxygen saturation on room air. Plan integrates bronchodilator and corticosteroid dosing per Global Initiative for Chronic Obstructive Lung Disease guidance.

SOAP note for low back pain in physical therapy

Low back pain notes include Oswestry Disability Index scores, straight-leg raise, neurological screening, and centralization testing. Treatment plan follows the Treatment-Based Classification system. Many students miss yellow flags; documenting psychosocial factors in Subjective is essential.

SOAP note for generalized anxiety in mental health

Generalized anxiety visits rely on Generalized Anxiety Disorder 7-item scale trending, Columbia Protocol for suicide screening, and homework adherence from prior sessions. The Plan must link interventions to the treatment phase of cognitive behavioral therapy or acceptance and commitment therapy.

Downloadable SOAP note templates

Every SOAP note template on EssayFount is HIPAA-safe, uses fictitious patient data, and aligns with the American Nurses Association and American Physical Therapy Association documentation principles.

Blank SOAP note template

The blank SOAP note template contains labelled Subjective, Objective, Assessment, and Plan fields, a space for vitals, a credential block, and a time-stamp line. Suitable for primary care, urgent care, and general clinical rotations.

Nursing SOAP note template

The nursing SOAP note template adds fields for North American Nursing Diagnosis Association International diagnoses, expected outcomes, and nursing interventions linked to the Assessment section, a pairing that fits ADPIE-based curricula.

Physical therapy SOAP note template

The physical therapy SOAP note template includes range-of-motion tables, manual muscle testing grid, functional outcome measure rows, and a long-term and short-term goal section aligned with Medicare documentation expectations.

Mental health progress note template

The mental health SOAP note template captures mental status exam components, suicide and homicide risk screening, substance use, and treatment-plan linkage. Session number and modality fields are included.

Common SOAP note mistakes to avoid

The same common SOAP note mistakes appear across nursing, physical therapy, and medical school rotations. Fixing them is the fastest route to a higher rubric score.

Mixing subjective and objective data

Writing "patient appears anxious" in Subjective is a mistake because "appears" is your observation. "Client reports feeling on edge" is Subjective. "Hands tremoring, speech rapid at 160 words per minute" is Objective.

Vague assessment language

"Patient stable" is not an assessment; it is a status word. Write "Type 2 diabetes mellitus, uncontrolled, secondary to medication non-adherence" instead. Attach the International Classification of Diseases, Tenth Revision code when coursework requires it.

Plan items that fail the SMART test

"Educate patient" is not a plan. "Teach carbohydrate counting with teach-back verification before discharge" passes the SMART goals test. Every plan item should answer who, what, when, and how much.

Inconsistent abbreviations

Stick to your facility's approved abbreviation list. Avoid dangerous forms such as "U" for units or "QD" for once daily. The Institute for Safe Medication Practices maintains a current "do not use" list.

Missing signatures or time-stamps

An unsigned or undated note is a legal liability. Sign with full credentials, record date and time, and label late entries as such.

SOAP compared with DAR, PIE, and narrative notes

SOAP is not the only documentation format. The DAR note comparison below helps students pick the correct structure when an instructor or a facility mandates an alternative.

When deciding between SOAP and DAR, ask which part of the encounter carries the most weight. SOAP suits multi-problem, differential-heavy encounters. DAR suits single-focus nursing shifts. For deeper format chains, see nursing care plan examples, discussion post examples, case study templates, lab report writing, and annotated bibliography examples.

SOAP notes inside nursing and physical therapy programs

Formal programs weave SOAP documentation into simulation, case study, and clinical rotations. Understanding how your program frames the task shortens the learning curve.

Shadow Health simulation SOAP notes

Shadow Health Digital Clinical Experiences end with a structured SOAP-style documentation step. Use the platform's Focused Exam rubric as your mapping guide. The Subjective section mirrors the Health History interview, the Objective section mirrors the Physical Examination, and the Assessment and Plan follow the case stem. Our model SOAP example for study helps students map evidence without replacing their own work.

iHuman case study SOAP notes

iHuman cases require a differential-heavy Assessment supported by the physical-exam findings the platform allows you to uncover. Model SOAP notes for study purposes demonstrate how to translate the platform's narrative into a clean SOAP structure, without shortcutting your decision-making.

Walden, Chamberlain, and Grand Canyon nursing SOAP assignments

Family nurse practitioner and adult gerontology programs at Walden University, Chamberlain University, and Grand Canyon University assign SOAP documentation at multiple points: NURS 6512, NURS 6531, NURS 6541, and parallel course codes. Rubrics commonly require International Classification of Diseases, Tenth Revision coding, Current Procedural Terminology billing codes, and evidence-based differentials citing UpToDate or the Agency for Healthcare Research and Quality.

Doctor of Physical Therapy clinical SOAP notes

Doctor of Physical Therapy students write SOAP notes throughout full-time clinical experiences, with weekly review by the clinical instructor. Expect formal critique on goal measurability, medical-necessity language, and billing alignment. For parallel coursework help, browse physical therapy homework and SOAP help, occupational therapy assignments, and physician assistant PANCE and SOAP help.