A SOAP note records a clinical visit in four parts: Subjective (what the patient reports), Objective (what you measure and examine), Assessment (your diagnosis and reasoning), and Plan (what happens next). Below are three full worked examples for different visits, each section annotated so you can see what belongs where, plus a blank template to copy.
The fastest way to learn the format isn’t a definition. It’s reading real notes and seeing why each line sits where it does. So that’s most of this page: a primary-care cold, a blood-pressure check, and an anxiety visit, written out in full, followed by a blank you can paste straight into your chart.
Key takeaways
- SOAP = Subjective, Objective, Assessment, Plan. Four sections, one encounter note, the same order every time.
- The Assessment is the section that fails most often. “Sore throat, query viral” is a restated complaint, not an assessment.
- Three full worked examples below cover an upper-respiratory visit, a hypertension follow-up, and a behavioral-health visit.
- A blank copy-paste template sits at the end. Steal it.
- Primary-care physicians log a median of 36.2 minutes of EHR time per 30-minute visit (JAMA Network Open, 2023). The note now outlasts the appointment.
SOAP sections: Subjective, Objective, Assessment, Plan
full worked example notes below, each section annotated
of EHR time per 30-minute primary-care visit (JAMA Network Open, 2023)
What does each SOAP section actually carry?
Quick version before the examples, because the examples make more sense once the buckets are clear. Per the StatPearls reference, the SOAP note is the standard documentation method for an encounter, and Dr. Lawrence Weed devised it about half a century ago as part of his problem-oriented medical record.
Subjective is the patient’s account. Chief complaint, history of present illness (onset, character, severity, what helps, what worsens), associated symptoms, and the past history that frames today’s visit. Their story, in clinical language. Not your interpretation.
Objective is what you observe and measure. Vitals, exam findings, results in front of you. Facts only. One discipline worth keeping: write only what you actually checked. “Abdomen soft, non-tender” when you never touched the abdomen is how a note becomes a liability.
Assessment is your clinical judgment. The working diagnosis, the differential, and the reasoning that connects the subjective and objective to it. This is the hardest section to write well and the one a reviewer or a covering colleague reads first.
Plan is what you do about it. Tests ordered, medications started or changed, referrals, patient instructions, follow-up interval. A decision you made in the room but left out of the Plan is a decision that didn’t happen, as far as the chart is concerned.
Worked example 1: an upper-respiratory visit (primary care)
A 29-year-old comes in with a few days of cold symptoms. This is the bread-and-butter acute visit. The illustrative note:
Subjective: 29-year-old presents with 3 days of sore throat, nasal congestion, and a dry cough. Reports low-grade fevers to 100.4F at home, worse in the evening. No difficulty swallowing solids, no ear pain, no shortness of breath. No sick contacts known. No chronic conditions, no regular medications, no known drug allergies. Has tried acetaminophen with partial relief.
Objective: Temp 99.1F, HR 78, BP 122/74, RR 14, SpO2 99% on room air. Alert, comfortable, not in distress. Oropharynx mildly erythematous, no tonsillar exudate. No anterior cervical lymphadenopathy. Tympanic membranes clear bilaterally. Lungs clear to auscultation, no wheeze or crackles.
Assessment: Acute viral upper respiratory infection. Presentation is consistent with a viral course: gradual onset, low-grade fever, no exudate, clear chest. Streptococcal pharyngitis unlikely given absent exudate, absent anterior cervical nodes, and presence of cough (Centor criteria low). No red flags for lower respiratory involvement.
Plan: Supportive care discussed: hydration, rest, acetaminophen or ibuprofen for fever and throat pain, saline nasal spray. No antibiotic indicated; rationale explained to patient. Return precautions given: shortness of breath, fever above 102F, symptoms beyond 10 days, or difficulty swallowing. Follow up if not improving in 7 to 10 days. No work note requested.
What’s worth noticing here. The Subjective carries the actual history, not just “sore throat.” The Objective records the exam that rules pharyngitis in or out, which is exactly what the Assessment then reasons about. The Assessment explains why this is viral instead of just labeling it, and the Plan does the unglamorous but legally important work: it documents that no antibiotic was given on purpose, and it spells out when to come back. That last line is the one busy notes drop.
Worked example 2: a hypertension follow-up
A 54-year-old returns to review blood pressure six weeks after starting a medication. Follow-up visits trip people up because the Subjective is thinner and the Assessment has to compare today against last time. The illustrative note:
Subjective: 54-year-old returns for hypertension follow-up, 6 weeks after starting amlodipine 5 mg daily. Reports good adherence, no missed doses. No headaches, no chest pain, no palpitations, no ankle swelling. Has been checking home BP most mornings, averaging around 140/88. Reports cutting back on added salt; has not yet started regular walking. No new medications or supplements.
Objective: BP 142/90 right arm seated, repeat 138/88 after 5 minutes. HR 72 regular. Weight 92 kg (down 1 kg from last visit). No peripheral edema. Heart sounds normal, no murmurs. Home BP log reviewed: morning readings 135 to 145 systolic over the past 3 weeks.
Assessment: Essential hypertension, not yet at goal on amlodipine 5 mg. Home and office readings agree, so this is not white-coat effect. Tolerating current therapy without side effects. Stage 2 by office reading; lifestyle modification partially adopted. Reasonable to intensify pharmacotherapy while reinforcing non-pharmacologic measures.
Plan: Increase amlodipine to 10 mg daily. Continue home BP monitoring, morning and evening, log to bring next visit. Reinforced salt reduction; set a starting goal of a 15-minute walk most days. Basic metabolic panel ordered to recheck renal function and electrolytes. Follow up in 4 weeks to reassess BP and tolerance. Return sooner for swelling, dizziness, or BP above 180/110.
The thing this example teaches is the comparison move. A follow-up Assessment is almost useless if it just says “hypertension.” The useful version says where the patient is relative to the plan: on treatment, not yet at goal, tolerating it, real (not white-coat). Everything in the Plan then follows from that one sentence. Note also that the Objective records two BP readings and the home log, because the Assessment leans on agreement between them.
Worked example 3: a behavioral-health visit
A 41-year-old presents with worsening anxiety. Behavioral-health notes lean harder on the Subjective and Assessment, and the Objective shifts toward mental-status observations and a screening score. The illustrative note:
Subjective: 41-year-old presents with 2 months of increasing anxiety, describing constant worry about work and finances, trouble falling asleep, and a “wired but tired” feeling most days. Reports irritability and difficulty concentrating. Denies panic attacks. Denies suicidal ideation, no thoughts of self-harm, no plan. No alcohol or substance use beyond occasional coffee. Taking sertraline 50 mg daily for 4 weeks, started by primary care, reports it “might be helping a little.”
Objective: Alert, cooperative, well-groomed. Speech normal in rate and volume. Mood reported as “on edge,” affect anxious but reactive. Thought process linear and goal-directed. No psychosis. GAD-7 administered this visit: score 14 (moderate to severe anxiety), down from 17 at the prior visit. Insight and judgment intact.
Assessment: Generalized anxiety disorder, moderate to severe by GAD-7, showing early partial response to sertraline at 4 weeks. Trajectory is downward (17 to 14), consistent with a medication that has not yet reached full effect. Risk is low: no suicidal ideation, no self-harm, stable support. Sleep disturbance is a prominent and treatable feature.
Plan: Continue sertraline 50 mg daily; full effect can take 6 to 8 weeks, so hold current dose and reassess. Discussed sleep hygiene and a brief breathing exercise for evening worry. Provided referral information for cognitive behavioral therapy. GAD-7 to be repeated at next visit to track response. Follow up in 3 weeks. Patient given crisis-line information and advised to return sooner if mood worsens or any thoughts of self-harm emerge.
Two things to call out. First, the Objective here is the mental-status exam plus a validated score (GAD-7), which gives you something to track instead of a vibe. Second, the risk statement in the Assessment is not optional in behavioral health; “no suicidal ideation, no plan, stable support” belongs in the note even when the answer is reassuring. If your visits are mostly behavioral-health, the mental-health SOAP note guide goes deeper into formulation and includes a rubric for grading a draft.
A blank SOAP note template you can copy
Here’s the reusable skeleton. Paste it into your chart and fill each line. The prompts in brackets are reminders, not text to keep.
Subjective: [Chief complaint in the patient’s words] [History of present illness: onset, character, severity, what helps/worsens, associated symptoms] [Relevant past history, current medications, allergies] [Pertinent negatives the patient reports]
Objective: [Vitals: BP, HR, RR, temp, SpO2, weight if relevant] [General appearance] [Focused exam findings: only what you actually checked] [Results reviewed today: labs, imaging, screening scores]
Assessment: [Working diagnosis, stated plainly] [Differential and the reasoning that supports or excludes it] [For follow-ups, where the patient is relative to the plan: at goal, improving, tolerating treatment] [Risk statement where relevant]
Plan: [Investigations ordered] [Medications started, changed, or continued, with dose] [Referrals] [Patient instructions and education given] [Return precautions / red flags] [Follow-up interval]
Keep the order fixed and the section labels explicit. The structure is the whole point: a reader should be able to jump to the Assessment without hunting for it. If you want the same skeleton with the four sections explained line by line for an Indian OPD context, the SOAP full-form and format breakdown covers that.
How an AI scribe drafts the SOAP note from the conversation
Filling that template by hand, on every patient, is the part that follows you home. A 2023 JAMA Network Open study found primary-care physicians logged a median of 36.2 minutes of EHR time per 30-minute visit. The note now takes longer than the appointment it describes. That’s the gap an ambient scribe is built to close.
The AI Medical Scribe is one module inside Practice Copilot, Patient Square’s AI platform for the whole practice. It listens during the visit and hands back a structured SOAP note, ICD-10 suggestions, and a prescription draft, ready to review and sign about two minutes after the visit.
In practice, that flips your job from writing to editing. The scribe maps the conversation onto the four sections: the Subjective from what the patient reported, the Objective from the findings you said out loud, the Assessment and Plan from your stated reasoning and the decisions you made in the room. You read the draft, correct anything off, and sign. The ICD-10 entries are suggestions you confirm, not codes filed for you. The prescription is a draft too, built from the plan you stated; you check the drugs, doses, and instructions and sign. It doesn’t run an automated interaction check, so the prescribing call stays yours, the same as when you write it by hand.
A few honest limits. The Assessment is where you should spend your review time, because synthesizing your reasoning is harder for a model than transcribing what was said; grade that section first on your own visits. The note comes out in clean clinical English. The visit audio is processed in memory and discarded the moment the draft is ready, so there’s no recording sitting in an archive. If you want a way to judge whether a drafted note is actually good enough to sign, the SOAP note quality rubric gives you six points to score it on, and the generator comparison lays out how the ambient tools differ.
The examples above are the bar. A drafted note should read like one of them after a quick edit, not like a transcript you have to rebuild. The way to know is to run it on real visits, not a demo. You can book a demo to watch a structured SOAP note appear about two minutes after a sample visit, then try it for a week on your own patients and read every draft closely.