The SOAP note template every clinician should have memorized (with examples)

Lawrence Weed introduced the SOAP note in 1968 as a way to force problem-oriented thinking into medical charts. Six decades later, it is still the most-used structure in ambulatory documentation — because it works. Subjective, Objective, Assessment, Plan. Four sections, one visit, no ambiguity about what belongs where. This guide is a practical breakdown of each section with real examples, plus a fill-in template you can adapt for your specialty in five minutes.

S — Subjective

The patient’s story in their own words. Chief complaint, history of present illness (HPI), pertinent past medical history, medications, allergies, family and social history. The key discipline in this section is verbatim capture — write what the patient said, not your interpretation of it.

• Chief complaint. Single sentence, patient’s words. "Chest pain for two days" is a chief complaint. "Rule out MI" is not.
• HPI. Onset, location, duration, characterization, aggravating/alleviating, radiation, timing, severity (the OLD-CARTS mnemonic).
• Review of systems. Pertinent positives and pertinent negatives only. Long ROS templates that list 40 negatives obscure the signal.

Example (family medicine, viral URI): CC: Sore throat and cough for four days. HPI: 32yo F presents with progressive sore throat and non-productive cough. Denies fever, chills, or shortness of breath. Reports fatigue and mild frontal headache. No sick contacts identified. Not tested for COVID or strep. PMH significant for seasonal allergies. Medications: loratadine PRN.

O — Objective

Measurable, observable data. Vital signs, exam findings by system, laboratory results, imaging, and any procedures performed during the visit. Everything in this section should be reproducible by another clinician reviewing the same patient at the same time.

• Vitals. BP, HR, RR, T, SpO2, and BMI/weight if relevant.
• Physical exam. By system, focused on the chief complaint. General appearance is worth including in one clause — "well-appearing, in no acute distress" — because it anchors the acuity of the visit.
• Studies. Point-of-care testing, labs drawn during the visit, imaging performed same-day. Reference range or interpretation belongs here.

Example (same URI patient): Vitals: T 37.2, HR 76, RR 14, BP 118/72, SpO2 99%. General: Well-appearing, comfortable. HEENT: Erythematous posterior pharynx without exudate. Anterior cervical lymphadenopathy, tender to palpation. Lungs: Clear to auscultation bilaterally, no wheezes or crackles. Cardiac: RRR, no murmurs. Rapid strep negative.

A — Assessment

Your clinical impression. One or more numbered problems with a diagnosis (or differential) and any relevant reasoning. This is the section that most differentiates a good note from a great one — a great assessment forces the writer to commit to a diagnosis or a plan for figuring one out.

Example: 1. Acute viral upper respiratory infection. Presentation classic for viral etiology; rapid strep negative reduces likelihood of GAS pharyngitis. 2. Seasonal allergic rhinitis, contributing.

P — Plan

What happens next. Broken down by problem number if the assessment has more than one. Includes medications, procedures, referrals, patient education, and follow-up. Every element in the plan should be traceable to a problem in the assessment.

Example: 1. Viral URI: Supportive care with fluids, rest, acetaminophen 500-1000mg q6h PRN for symptomatic relief. Return-to-clinic if symptoms worsen or fever develops. Patient counseled on symptom red flags. 2. Allergic rhinitis: Continue loratadine daily during peak season. Consider referral to allergy if refractory next season.

The three most common SOAP mistakes

• Assessment that just restates the subjective. If the S is "sore throat for four days" and the A is "sore throat, patient endorses four days of symptoms," the A adds nothing. The A is where you commit.
• Plan that doesn’t match the assessment. If you list "asthma exacerbation" in the A, the P must include an intervention for the asthma. Otherwise the note reads like an afterthought.
• Copy-pasting objective findings from previous visits. This is the fastest way to a malpractice deposition. If you didn’t examine it today, don’t document it today.

Fill-in template

Copy the block below into your chart or Notes app and adapt for your specialty.

S — Chief complaint: [ ] HPI: [ ] ROS pertinent positives/negatives: [ ] PMH/Meds/Allergies: [ ]
O — Vitals: [ ] Exam by system: [ ] Studies: [ ]
A — 1. [Diagnosis with brief reasoning] 2. [ ]
P — 1. [Intervention, patient education, follow-up] 2. [ ]

Or, if you’d rather have every note structured this way automatically after a two-minute recording, start the ezScribe 14-day free trial. Every summary comes back in SOAP format by default, with ICD-10 suggestions in the plan.