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15 Templates & Examples for Clinical SOAP Note Format

Courtney Gardner, MSW

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As a mental health professional, do you struggle to keep track of your client's treatment progress? Do you have difficulty remembering the details of your last session when a client asks about their progress? Look no further than SOAP notes! They are the perfect solution to your documentation woes. SOAP notes provide a quick and systematic way to record your client's treatment, refresh your memory about past sessions, and facilitate seamless collaboration with colleagues.

In this comprehensive blog post, we'll unravel the mysteries of SOAP notes and equip you with the best SOAP note template and examples and everything you need to know. From their purpose to their importance and best practices, we'll dive deep into the world of SOAP notes, demystifying jargon. By the end, you'll produce SOAP notes quicker than ever and wonder how you managed without them. Whether you're a seasoned therapist or a new counselor just starting, SOAP notes are essential for elevating your documentation to the next level. So, fasten your seatbelt and prepare to explore the world of SOAP notes.

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Why Are SOAP Notes Important for Mental Health Practitioners?

SOAP notes are an invaluable tool for mental health practitioners, providing a structured and efficient way to document a client's treatment progress. But why exactly are SOAP notes so valuable? Let's explore:

Organized and Systematic :

SOAP notes follow a standardized format, ensuring that all relevant information is documented consistently. This allows mental health practitioners to review and understand the client's progress over time easily.

Enhanced Memory Recall :

With SOAP notes, there's no scrambling to remember the details of previous sessions. The subjective section captures the client's thoughts, feelings, and perceptions, while the objective section records concrete observations. This comprehensive documentation helps mental health professionals recall critical details and tailor their treatment approach accordingly.

Collaborative Care :

SOAP notes facilitate seamless collaboration among colleagues. By sharing SOAP notes, mental health practitioners can ensure continuity of care and provide insights to other professionals involved in the client's treatment. This collaborative approach enhances the quality of care and promotes effective interdisciplinary communication.

Evidence-Based Analysis :

The assessment section of SOAP notes is a crucial tool for mental health practitioners to analyze and interpret the subjective and objective information their clients provide. This evidence-based analysis establishes diagnoses, clinical impressions, and informed judgments about the client's issues or conditions. It guides treatment decisions and ensures interventions are based on sound clinical reasoning.

Goal-Oriented Planning :

One crucial section of the SOAP note is the plan section, which outlines the actions needed to address the client's issues or conditions. The plan section comprises setting achievable goals , identifying interventions, making referrals, and determining the next steps. By documenting this plan, mental health practitioners can track their client's progress, evaluate the effectiveness of interventions, and make necessary adjustments to achieve optimal outcomes.

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Common mistakes to avoid when writing soap notes.

A few common mistakes to avoid when documenting your clients' treatment plans :

Not Being Specific Enough.

Be as detailed as possible in your notes. Rather than writing "client discussed relationship issues," it's better to specify which issues were discussed and how the client felt. For example, "Client expressed frustration over lack of communication with a partner. Stated feeling unheard and underappreciated."

Leaving out Important Details.

It's easy to forget key details when you have a busy caseload, but your notes should capture the most important elements of each session. Note the client's mood and affect, discussion themes, interventions used, goals set, and plans for the next session. Avoid ambiguity in your notes to ensure you can easily refer to them.

Failing to Record the Client's Direct Quotes.

When possible, record the client's exact words and phrases as they provide valuable context and insight into their thoughts, feelings, and behaviors . Quote important statements about their symptoms, experiences, goals, and challenges.

Missing the "So What?"

Your notes should analyze themes, assess progress, discuss interventions, and reflect your clinical reasoning. Explain the significance of conversations, events, and any changes to the treatment plan.

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How to generate effective soap notes with examples.

SOAP notes are the bread and butter of documentation in healthcare. As a clinician, writing concise yet comprehensive notes is fundamental. Here are some additional tips for crafting clear SOAP notes:

Focus on One Client Issue per Note.

Avoid cramming multiple concerns into a single note, or it will become confusing.

Focus on the Subjective.

This is where you document the client's symptoms, behaviors, experiences, or life events since the last session. Ask open-ended questions to get details about intensity, frequency, and duration.

For example:

"Client reports feeling increasingly depressed over the past week with trouble sleeping, loss of appetite, and difficulty concentrating at work. States sadness is 8 out of 10 in intensity, occurring daily, and lasting most of the day."

Objectively Observe.

Note factual observations of the client's appearance, mood, affect, speech, and behavior, and avoid opinions or judgments.

"Client made little eye contact, slouched in their chair, and spoke softly. Appeared tired with flat affect."

Assess the Analysis

This is your chance to analyze subjective and objective data, provide a diagnosis or differential diagnosis, and evaluate any risks or contributing factors.

"Symptoms appear consistent with major depressive disorder, recurrent episodes. There are no apparent safety risks at this time. Stress at work and relationship difficulties likely contributing factors."

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Plan the intervention.

Explain the plan for treatment, including goals, interventions, frequency of sessions, referrals to other professionals, and any follow-up needed.

• Provide empathy, support, and coping strategies to improve mood and functioning.
• Discuss starting antidepressant medication to elevate mood.
• Increase sessions to twice weekly for the next month
• Follow up with psychiatrist regarding medication management.
• Develop a self-care plan to improve sleep, appetite, and daily activity.

SOAP Note Example and Template

Let's examine how to combine the SOAP note components using the SOAP format:

As a psychotherapist, therapist, or counselor, it is crucial to take comprehensive SOAP notes that document your client's mental and emotional state throughout their therapy sessions. Additionally, record any changes in their symptoms, progress, or setbacks in their therapy journey.

Some examples include:

Soap Note Example and Template Psychotherapists

S  (Subjective): The client reported feeling "stressed out" and "overwhelmed." Stated, "I've been worrying constantly and can't relax." Reported trouble sleeping for the past week.

O  (Objective): The client exhibited signs of anxiety, including rapid speech, leg shaking, and difficulty maintaining eye contact. Apologized frequently for "rambling."

A  (Assessment): Anxiety. Insomnia related to excessive worrying/stress.

P  (Plan): Discussed relaxation and mindfulness techniques for anxiety management. Recommended limiting screen time and stressful activities before bed. Will follow up in two weeks.

Soap Note Example and Template Therapists

S : The client reported experiencing high stress levels and feeling "crushed" over the past week. States trouble sleeping, concentrating, and increased anxiety.

O : The client presented as restless and fidgety. Speech rapid. Affect mildly anxious. Insight and judgment intact.

A : Anxiety related to increased work responsibilities and deadlines. Stress and worry cause difficulty regulating emotions and focus.

P : Discussed stress management and relaxation techniques such as controlled breathing, meditation, and limiting caffeine/screen time before bed. Referred client to online anxiety coping strategies and recommended decreasing workload if possible and planning enjoyable activities. Follow up in two weeks.

Soap Note Example and Template Counselors

S : The client states, "I've been struggling" with a depressed mood for the past month. Endorses feelings of hopelessness, low energy, and changes in sleep and appetite—no suicidal ideation .

O : Appearance disheveled. Psychomotor impairment is evident. Speech slowed. Affect depressed and tearful at times. Insight is good, and judgment is intact.

A : Major Depressive Disorder, recurrent episodes, moderate.

P : Discussed therapeutic options of medications and therapy. Therapist recommended seeing a psychiatrist for medication evaluation and follow-up with therapy and referred them to community support groups. Safety plan established. Follow up in one week.

Soap Note Example and Template for for Social Workers

Social workers emphasize documenting environmental and social factors related to their clients in SOAP notes. For instance, these notes outline the client's living arrangements, family and social connections, and access to resources that may improve their overall well-being.

S : The client reported ongoing conflict with a neighbor regarding noise complaints, causing distress. States the situation has led to anger, frustration, and hopelessness.

O : The client was irritable during the interview but was cooperative—no evidence of dangerousness to self or others.

A : Stress and impaired coping related to interpersonal conflict and environmental issues.

P : Discussed conflict resolution strategies and options for improving the situation, including neighbor mediation. Referred client to the local housing authority regarding options for moving away from conflict. Will see the client again in two weeks to reassess coping and check on progress with mediation/housing options.

S : The client says they are having trouble paying rent and buying food this month and are expressing frustration over the lack of family support.

O : The client was petulant but maintained an agreeable attitude throughout. No evidence of substance abuse. Living in subsidized housing and receiving food stamps.

A : The client is in a financial crisis due to losing a part-time job. Lack of financial literacy and family support system are contributing factors.

P : Refer the client to a job placement program and financial counselor. Help apply for additional food stamps and utility assistance. Follow up on job and financial counseling progress.

Soap Note Example and Template for for Psychiatrists

Psychiatrist SOAP notes will primarily concentrate on the medical aspects of their treatment plan, such as the management of their medication regimen. This includes details on the medications prescribed, their dosages, and the client's response to medication. It also involves tracking any side effects that the client may experience, as well as any adjustments made to their medication regimen in response to changes in their condition.

Examples include:

S : The client reported medication is stabilizing mood; however, continues to struggle with the side effects of sedation and weight gain. Stated mood has been "okay," but motivation and energy remain low.

O : Psych exam within normal limits. No suicidal or homocidal ideation. Weight gain of 10 lbs since last visit, possibly related to medication.

A : Bipolar I disorder, current episode depressed. Improved with medication but suboptimal response due to side effects.

P : Discussed options for switching or augmenting medications to address residual symptoms better while minimizing side effects. Will start the client on Wellbutrin 150 mg in the AM in addition to current meds. Follow up in four weeks to reassess symptoms, medication effects/side effects, and functioning.

S : The client reports feeling increasingly depressed and anxious over the past month, with trouble sleeping, poor concentration, and loss of interest in activities. Claims relationship issues and work stress are contributing factors.

O : The client appears disheveled and fatigued. Speech is coherent but slowed. Mood is dysphoric, and affect is constricted. No evidence of psychosis or suicidal ideation.

A : Major depressive disorder , recurrent, moderate. Generalized anxiety disorder .

P : Continue current medications (Lexapro 20mg, Buspirone 15mg) with follow-up in four weeks. Recommended beginning weekly psychotherapy to address contributing stressors and coping strategies. Encouraged regular exercise, limiting alcohol/caffeine intake, and maintaining a routine sleep schedule. Will re-evaluate symptoms and medications at the next visit. Instructed client to call if symptoms worsen or side effects develop.

Some more templates and examples.....

Whether you're a nurse responsible for keeping patients comfortable, an occupational therapist (OT) helping clients live independently, or a speech-language therapist (SLP) supporting communication, you must create precise and tailored SOAP notes to document your patients' progress. To do this, focus on subjective reports, objective observations, assessments matching your scope of practice, and practical plans for helping your patients.

To help you get started, here are some examples to guide you:

Soap Note Example and Template for for Nurses

S : Patient reports increased pain in the lower back, rating 7/10. The patient appears uncomfortable.

O : Lower back tenderness to palpation. Pain worsens with movement. Vital signs stable.

A : Acute exacerbation of chronic lower back pain.

P : Administer Ibuprofen 600 mg PO. Apply a heating pad to the lower back. Refer to the physician if pain persists for more than three days.

S : Patient complains of pain and difficulty walking due to recent knee surgery.

O : Knee incision site is healing well, with no sign of infection. The patient can bend their knee 30 degrees. Leg muscles feel weak when walking.

A : Impaired mobility and muscle weakness related to knee surgery.

P : Assist patient with walking and knee exercises. Provide pain medication as needed. Re-evaluate mobility and pain in two days.

Soap Note Example and Template for for Occupational Therapists

S : Patient reports difficulty grooming and dressing due to a decreased range of motion in the dominant right arm.

O : Active range of motion in right shoulder flexion limited to 90 degrees. Grip strength 4/5.

A : Impaired range of motion and strength in the right arm, limiting independence with self-care.

P : Recommend continued home exercise program. Added towel stretch for their shoulder. Follow up in two weeks to reassess range of motion and strength.

S : Patient has decreased range of motion and strength in dominant right hand after elbow fracture. Has difficulty with activities of daily living like eating, bathing, and dressing.

O : Grip strength measures 10 lbs in their right hand compared to 35 lbs in their left hand. Right wrist extension limited to 15 degrees.

A : Limited mobility and dexterity impairing independence.

P : Provided hand exercises to improve range of motion and strength. Recommend using adaptive equipment like button hooks, jar openers, and utensil holders to assist with activities of daily living. Follow up in one week to reassess and provide additional recommendations as needed.

Soap Note Example and Template for for Speech Therapists

S : Patient exhibitied word-finding difficulties, prolonged pauses in conversation, and repetition of phrases.

O : Decreased verbal fluency noted on assessment—difficulty naming objects and generating lists.

A:  Possible mild cognitive impairment or early dementia. Further assessment is needed.

P : Referred patient to a physician for neurological workup, including brain imaging. Provided patient and family education on communication strategies—schedule follow-up appointment pending physician findings.

S : Patient has difficulty speaking clearly due to muscle weakness from stroke. Speech is slurred and hard to understand.

O : Oral musculature appears uneven and drooping on the right side of the mouth. Tongue deviates to the right when protruded.

A : Dysarthria related to right-side facial and tongue muscle weakness.

P : Recommend speech therapy focusing on tongue and lip exercises to improve muscle tone and control. Provide communication strategies like speaking slowly, over-articulating words, and using gestures to supplement speech. Re-evaluate speech clarity in three weeks after therapy.

Are you ready to take your client documentation to the next level? With consistent practice, you'll develop the skills to capture all the essential details that reflect your daily meaningful work helping your clients. Imagine reaching new heights in your organizational skills by keeping good records of your sessions and maintaining clear communication. Your clients and colleagues will thank you for producing clear, concise, valuable notes to help you make data-driven treatment decisions. With consistently high-quality notes, you'll be able to identify trends and have records that will withstand the highest scrutiny. Remember, the key is to stick with it, use templates and examples, and develop a system. You can refer back to this guide anytime you need a refresher. Now go forth and document, and let your work positively impact your clients' lives.

If you need motivation to dive into your documentation journey, try Mentalyc! Our platform is designed to help you maintain clear communication and stay organized so that you can focus on what matters most - providing top-notch care to your clients. With Mentalyc, you get more than just speedy note-taking. You get a versatile and adaptable platform to personalize your notes and use the language you and your team are most comfortable with. Our intuitive interface makes navigating through different sections easy and captures all the essential details of each session. Plus, with customizable templates and the ability to adapt the SOAP format to your needs, you can quickly create comprehensive yet concise notes. Say goodbye to the headache of note-taking and hello to the ease and convenience of Mentalyc. Join us today and revolutionize your note-taking process!

FAQ on SOAP Notes: Answering Common Questions From Mental Health Professionals

As a mental health professional, you may have questions about documenting client care with SOAP notes. Below are answers to some common questions that will make the process more straightforward.

Do SOAP notes need to be written in a particular format?

Although the layout can vary, SOAP notes should follow a consistent and logical format. The SOAP format is commonly used, but you can adapt it to best suit your needs. Most importantly, your notes are clear, concise, and chronological.

The SOAP format:

S : Subjective (client quotes, current symptoms)

O : Objective (mental status, observations)

A : Assessment (diagnosis, case conceptualization)

P : Plan (treatment, recommendations)

Should I use whole sentences or bullet points?

You can write your SOAP notes in complete sentences or bullet points format. Full sentences can provide more detailed and descriptive information, enhancing the flow of the session's narrative. On the other hand, bullet points help list the essential topics of the conversation or the different steps of an intervention. It's important to use a style that works best for you and the specifics of each note.

What tense should I write in?

Writing SOAP notes in the past tense is important as they document what occurred during the session. For instance, instead of writing "The client reports feeling anxious and stressed at work," write "The client reported feeling anxious and stressed at work." However, in the Plan section, where future actions and goals are discussed, you can write in the present or future tense.

How should I organize each section?

The Subjective and Objective sections typically flow chronologically to tell the story of what was discussed and observed during the session. The Assessment section can be organized by each issue discussed or by themes that connect problems. The Plan section is usually organized regarding short-term goals, long-term goals, interventions, referrals, and follow-up.

What if a session runs long or short? Do I need to modify the SOAP note?

The SOAP note should accurately reflect the care provided in each session, regardless of length. If a session runs shorter or longer, simply document what was covered and any recommendations or follow-up needed. The most important thing is that the SOAP note matches the actual session.

What if nothing significant happened in a session? Do I still need a SOAP note?

Yes, a SOAP note is required for every session, even if the session was uneventful. Briefly document the topics discussed, the client's current symptoms or functioning, and any recommendations.

Do I need to use medical terminology?

Use terminology that you and other providers in your practice will understand. Explain any complex terms or abbreviations. The notes should be clear and concise while accurately representing the critical aspects of the session.

What if I make a mistake?

Making mistakes while writing SOAP notes is common; nobody is perfect. It's a good idea to proofread your notes and double-check critical information, such as medication names or diagnoses, to reduce the chances of errors. If you notice any mistakes, draw a line through the incorrect information, initial and date it, and then write the correct information. Never scribble over or white out errors.

What if I don't have a lot of details for the objective section?

Don't worry if you only have one or two objective findings. The important thing is to document what you observed. You can state, "No new symptoms reported."

Compliancy Group. (2023, July 25).   8 common clinical documentation mistakes . https://compliancy-group.com/common-clinical-documentation-mistakes/

Miller, K. D. (2020, April 3).   What are soap notes in Counseling? (+ examples) . PositivePsychology.com. https://positivepsychology.com/soap-notes-counseling/

Podder, V., Ghassemzade, S., & Lew, V. (2022, August 29).   SOAP Notes . National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK482263/

All examples of mental health documentation are fictional and for informational purposes only.

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Writing SOAP Notes, Step-by-Step: Examples + Templates

Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient’s care.

In a few sections, we’ll give a clear overview of how therapy SOAP notes are written, along with helpful templates and software you can use to streamline the process even further. If you’re looking for a more efficient, concise way to document your telehealth sessions, this helpful guide will be of value.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely. [1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status. This information can be shared with other stakeholders involved in their wellbeing for a more informed, collaborative approach to their care, as shown:

It’s critical to remember that digital SOAP notes must be shared securely and privately, using a HIPAA-compliant teletherapy platform . Here, we used Quenza.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

• Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.
• Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
• Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
• Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes , the SOAP format itself is a useful checklist for clinicians while documenting a patient’s therapeutic progress.[REFERENCE ITEM=”Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9 (4), 576.”]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your P rogress Notes, as well as the speed with which you write them. 

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following example that you can use as guidance in your work. [1]

Occupational Therapy SOAP Notes

In Occupational Therapy , a SOAP Progress Note might include the patient’s injuries and their severity, home exercises, and their effectiveness.

Based on observations and interaction with their client, an OT professional might adjust their treatment program accordingly. [2]

Laid out in the S, O, A, P format on therapy notes software , they might look like this:

Digital SOAP note tools like Quenza, which we’ve used here, will automatically create PDF copies for download, sharing, or HIPAA-compliant storage in a centralized place.

Because SOAP notes are best created while a session is still fresh in their minds, therapists might look for mobile-compatible software. This way, notes can be made on the spot from a tablet or smartphone.

Recommended: How to write Occupational Therapy SOAP Notes (+3 Examples)

Applied Behavior Analysis SOAP Notes

SOAP notes also play a valuable role in Applied Behavior Analysis , by allowing professionals to organize sessions better and communicate with a client’s other medical professionals. Legally, they may also accompany insurance claims to evidence the service being provided. [3]

It is important to remember that ABA SOAP notes , as psychotherapeutic documents, must be stored privately. They may form part of a client’s overall medical file other therapy notes.

These illustrative Occupational Therapy SOAP Notes and ABA SOAP Notes also exemplify how versatile SOAP notes can be. [4]

It’s why the framework is a commonly used standard in sectors such as Physical Therapy , Nursing, Rehabilitation, Speech Therapy , and more.

5 Examples of Effective Note-Taking

Many therapy software systems help to speed up the documentation of progress notes through in-built templates and diagnostic codes. At the end of the day, however, clinically valuable notes require careful thought and judgment when it comes to their content.

Effective notes are generally: [5]

• Written immediately following a therapy session. This way, a practitioner’s in-session time is spent focused on patient engagement and care ; writing notes immediately after helps minimize common mistakes such as forgetting details or recall bias.
• Professional. An important part of patient Electronic Health Records , SOAP notes should be legible and make use of professional jargon to serve as a common frame of reference. They should be written in the present tense.
• Concise and specific. Overly wordy progress notes unnecessarily complicate the decision-making process for other practitioners involved in a patient’s care. Brief, but pertinent information helps other providers reach conclusions more efficiently.
• Unbiased: In the Subjective section, particularly, there is little need for practitioners to use weighty statements, overly positive, negative, or otherwise judgmental language. SOAP notes are frequently used both as legal documents and in insurance claims.
• Utilize appropriate details, such as direct quotes: For a more comprehensive document that includes all the salient facts of an encounter.

An effective SOAP note is a useful reference point in a patient’s health record, helping improve patient satisfaction and quality of care.

3 Smart Software Solutions

In this section, we’ve reviewed three of the top  practice management software systems offering helpful SOAP note functions.

These include SOAP note templates, discipline-specific codes, and treatment planning features that integrate with therapy progress notes.

Importance of Accurate and Detailed SOAP Notes

Accurate and detailed SOAP notes are crucial in ensuring effective patient care. They serve as a comprehensive record that provides continuity and clarity in treatment. Detailed notes help in tracking patient progress, identifying patterns, and making informed decisions about future care plans. They also facilitate clear communication among healthcare providers, reducing the risk of errors and misinterpretations.

Moreover, thorough SOAP notes are essential for legal documentation and compliance. They provide a clear, chronological record of patient interactions and clinical decisions, which can be invaluable in case of audits or legal inquiries. Inaccurate or incomplete notes can lead to misunderstandings, compromised patient care, and potential legal repercussions.

Additionally, precise documentation supports better patient outcomes. When healthcare providers have access to accurate and complete information, they can make more effective treatment decisions. This leads to improved patient satisfaction, as patients receive consistent and well-coordinated care. Accurate notes also contribute to research and quality improvement initiatives by providing reliable data for analysis.

Tips for Enhancing SOAP Note Quality

Improving the quality of your SOAP notes can significantly impact patient care and clinical efficiency. Here are some practical tips for enhancing your note-taking:

• Be Clear and Concise: While it’s important to be thorough, avoid unnecessary details that don’t contribute to the patient’s care. Focus on relevant information that supports clinical decision-making.
• Use Standardized Language and Abbreviations: Consistency in terminology and abbreviations helps ensure that all healthcare providers understand the notes. Avoid using uncommon abbreviations that might cause confusion.
• Incorporate Patient Quotes: Including direct quotes from patients can provide valuable context and insight into their condition and concerns. This practice helps capture the patient’s perspective and can aid in more personalized care.
• Regularly Review and Update Notes: Make it a habit to review and update notes regularly to ensure they remain accurate and relevant. This is particularly important for patients with chronic conditions or those undergoing long-term treatment.

By implementing these tips, healthcare providers can create more effective and reliable SOAP notes, ultimately enhancing patient care and clinical outcomes.

Ensuring SOAP Notes are Client-Centered

Client-centered SOAP notes prioritize the unique needs and experiences of the patient, enhancing therapeutic outcomes. Therapists can create a more tailored and effective treatment plan by focusing on individual goals, preferences, and feedback. This approach improves client satisfaction and fosters a collaborative therapeutic relationship, promoting active participation and commitment to the treatment process.

Incorporating Client Feedback: Gathering regular client feedback can provide invaluable insights into their experiences and progress. This can be done through direct questions during sessions or via follow-up questionnaires. By documenting this feedback in the Subjective section, therapists can adjust their strategies to better meet the client’s needs, ensuring that the therapy remains relevant and impactful.

Personalizing Treatment Plans: Each client’s treatment plan should reflect their personal goals and challenges. The Plan section of SOAP notes outlines specific actions tailored to the client’s circumstances. For example, if a client struggles with anxiety in social situations, the plan might include exposure therapy techniques or social skills training designed specifically for their context and preferences.

Building a Collaborative Relationship: A collaborative approach involves the client in decision-making, enhancing their sense of agency and investment in therapy. During the Assessment phase, discuss the client’s perspective on their progress and any concerns they might have. This helps create a more accurate assessment and empowers the client, fostering a more cooperative and effective therapeutic environment.

Tracking Individual Progress: Regularly reviewing and updating SOAP notes ensures that the therapy remains dynamic and responsive to the client’s evolving needs. Documenting specific achievements and challenges in the Objective section helps monitor progress over time, allowing for timely adjustments to the treatment plan. This continual adaptation is crucial for maintaining the therapy’s relevance and effectiveness.

Leveraging Technology for Efficient SOAP Note Management

With the advent of digital tools, managing SOAP notes has become more efficient and secure. Utilizing specialized software can significantly reduce the administrative burden, allowing therapists to focus more on patient care. These technologies offer features such as templates, automatic data entry, and secure storage, which streamline the documentation process and enhance data accuracy.

Digital Templates and Auto-fill Features: Many therapy software solutions provide customizable templates that simplify the process of writing SOAP notes. These templates ensure that all necessary information is captured systematically. Auto-fill features can further expedite note-taking by automatically inserting recurring details, such as client demographics and session dates, thus saving time and reducing the risk of errors.

Secure Storage and Compliance: Ensuring the confidentiality and security of client information is paramount. Digital platforms that comply with HIPAA and other relevant regulations offer encrypted storage solutions, protecting sensitive data from unauthorized access. This secure environment safeguards patient privacy and facilitates easy retrieval and sharing of notes when needed for collaborative care.

Integration with Practice Management Systems: Integrating SOAP note software with broader practice management systems can enhance overall efficiency. Such integration allows for seamless coordination between scheduling, billing, and documentation. For instance, notes from therapy sessions can be directly linked to billing codes, simplifying the administrative workflow and reducing the likelihood of discrepancies.

Real-time Data Access and Updates: Mobile-compatible software lets therapists update SOAP notes in real-time, even during sessions. This immediate documentation ensures that details are accurately recorded while they are still fresh in the therapist’s mind. Moreover, having access to notes on the go allows therapists to review patient history and progress at any time, facilitating more informed and responsive care.

Final Thoughts

With clear, consistent information on a patient’s health status and progress, therapists, psychiatrists, and counselors are much better equipped to manage their well-being. And while note-taking may not be glamorous, harnessing the right software can significantly reduce the time you spend on this vital part of healthcare .

SOAP notes play a pivotal role in streamlined, effective healthcare, and are a daily part of life for many practitioners. If you’ve tried and enjoyed using any particular templates, forms, or therapy notes solutions, let us know in a comment.

We hope this article has helped you streamline your note-taking. To put these tips into practice, don’t forget to try Quenza’s SOAP Notes tools for just $1 a month .

If you want to enhance the wellbeing of your clients more effectively, Quenza will give you everything you need to streamline your therapy notes, so you can focus on delivering the wellness results that matter.

• ^ Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
• ^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes.. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy
• ^ WebABA. (2020). Simple Guidelines for Writing SOAP Notes. Retrieved from https://webaba.com/2020/07/01/aba-practice-daily-simple-guidelines-for-writing-soap-notes/
• ^ Belden, J. L., Koopman, R. J., Patil, S. J., Lowrance, N. J., Petroski, G. F., & Smith, J. B. (2017). Dynamic electronic health record note prototype: seeing more by showing less. The Journal of the American Board of Family Medicine, 30 (6), 691.
• ^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy

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15 SOAP Note Examples in 2024

By Jamie Frew on Aug 13, 2024.

Fact Checked by Nate Lacson.

Introduction

SOAP notes are a widely used and accepted format by healthcare practitioners, from mental health professionals to physicians and social workers, to capture client information in an easy-to-understand way. Using a SOAP note format, clinicians can ensure they extract valuable information from patients in both a subjective and objective manner. Using the information gathered, healthcare professionals can then assess the patient for a viable and effective treatment plan in response to their clinical diagnosis.

You probably already know this, but SOAP is an acronym that stands for subjective, objective, assessment, and plan. Each letter refers to the different components of a soap note and helps outline the information you need to include and where to put it.

Even though SOAP notes are a simple way to record your progress notes, having an example or template is still helpful. That's why we've taken the time to collate some SOAP note examples. They can be useful in helping you write more detailed and concise notes from the subjective and objective data to the planning part.

How to write a SOAP note

Although every practitioner will have their preferred methods for writing SOAP notes, there are helpful ways to ensure you cover all the correct information. We've already covered the type of information that should be covered in each section of a SOAP note, but here are some additional ways to guarantee this is done well. 

The subjective section covers how the patient feels and what they report about their symptoms. The main topic, symptom, or issue that the patient describes is known as the chief complaint (CC). There may be more than one CC, and the primary CC may not be what the patient initially reports on. As their physician, you need to ask them as many questions as possible so you can identify the appropriate CC. 

A history of present illness (HPI) also belongs in this section. This includes questions like:

• When did the symptoms begin?
• When did you first notice the CC?
• Where is the CC located?
• What makes the CC better?
• What makes the CC worse?

Pro tip #1 : It is a good idea to include direct quotes from the patient in this section. 

Pro tip #2:  Writing the subjective section needs to be concise. This may mean compacting the information the patient has given you to get the information across succinctly. 

The objective section includes the data that you have obtained during the session. This may include:

• Vital signs
• Laboratory results
• X-ray results
• Physical exam

Based on the subjective information that the patient has given you and the nature of their CC, you will respond appropriately and obtain objective data that indicates the signs of the CC. 

In addition to gathering test/lab results and vital signs, the objective section will include your observations about how the patient presents. This has their behavior, effect, engagement, conversational skills, and orientation. 

Pro tip #3 : Confusion between symptoms and signs is common. The patient's symptoms should be included in the subjective section. In contrast, signs refer to quantifiable measurements or objective observations you have gathered indicating the presence of the CC.

It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan. 

If there are several different CCs, you may want to list them as ‘problems,' as well as the responding assessments. Practitioners frequently use the assessment section to compare their patients' progress between sessions, so you want to ensure this information is as comprehensive as possible while remaining concise. 

Pro tip #4 : Although the assessment plan synthesizes information you've already gathered, you should never repeat yourself. Don't just copy what you've written in the subjective and objective sections. 

The final section of a SOAP note covers the patient's treatment plan in detail based on the assessment section. You want to include immediate goals, the date of the next session (where applicable), and what the patient wants to achieve between their appointments. 

In future sessions, you can use the plan to assess the patient's progress and determine whether the treatment plan needs to be changed. 

The plan section may also include:

• Referrals to specialists
• Patient education
• Medications
• If further testing is required
• Progression or regression made by the client

Although every practitioner will have their preferred methods for writing SOAP notes, there are helpful ways to ensure you cover all the correct information. We've already covered the type of information that should be covered in each section of a SOAP note, but here are some additional ways to guarantee this is done well. 

The subjective section covers how the patient feels and what they report about their symptoms. The main topic, symptom, or issue that the patient describes is known as the Chief Complaint (CC). There may be more than one CC, and the primary CC may not be what the patient initially reports on. As their physician, you need to ask them as many questions as possible so you can identify the appropriate CC. 

A History of Present Illness (HPI) also belongs in this section. This includes questions like:

Pro tip #1 : It is a good idea to include direct quotes from the patient in this section. 

Pro tip #2:  Writing the subjective section needs to be concise. This may mean compacting the information the patient has given you to get the information across succinctly. 

Based on the subjective information that the patient has given you and the nature of their CC, you will respond appropriately and obtain objective data that indicates the signs of the CC. 

In addition to gathering test/lab results and vital signs, the objective section will include your observations about how the patient presents. This has their behavior, effect, engagement, conversational skills, and orientation. 

Pro tip #3 : Confusion between symptoms and signs is common. The patient's symptoms should be included in the subjective section. In contrast, signs refer to quantifiable measurements or objective observations you have gathered indicating the presence of the CC.

It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan. 

If there are several different CCs, you may want to list them as ‘Problems,' as well as the responding assessments. Practitioners frequently use the assessment section to compare their patients' progress between sessions, so you want to ensure this information is as comprehensive as possible while remaining concise. 

Pro tip #4 : Although the assessment plan synthesizes information you've already gathered, you should never repeat yourself. Don't just copy what you've written in the subjective and objective sections. 

The final section of a SOAP note covers the patient's treatment plan in detail based on the assessment section. You want to include immediate goals, the date of the next session (where applicable), and what the patient wants to achieve between their appointments. 

In future sessions, you can use the plan to identify the patient's progress and judge whether the treatment plan requires changing. 

SOAP note examples and templates

Although the above sections help outline the requirements of each SOAP notes section, having an example in front of you can be beneficial. That's why we've taken the time to collate some examples and SOAP note templates, which we think will help you write more detailed and concise SOAP notes.

SOAP note example for nurses or nurse practitioners

John reports feeling tired and struggling to get out of bed in the morning. He also struggles to get to work and constantly finds his mind wandering to negative thoughts. John stated that his sleep had been broken, and he did not wake feeling rested. He reports that he does not feel as though the medication is making any difference and thinks he is getting worse.

John could not come into the practice and has been seen at home. John's personal hygiene does not appear to be intact; he was unshaven and dressed in track pants and a hooded jumper, which is unusual as he typically takes excellent care of his appearance. John appears to be tired. He has a pale complexion and large circles under his eyes.

John's compliance with his new medication is good, and he appears to have retained his food intake. Weight is stable and unchanged.

The client's symptoms are consistent with a major depressive episode. This is evidenced by his low mood, slowed speech rate and reduced volume, depressed body language, and facial expression. However, it's important to note that this assessment is based on the information presented, and a full diagnosis can only be confirmed by a qualified mental health professional.

Further exploration is needed to understand the duration and severity of these symptoms, as well as any potential contributing factors such as life stressors, relevant medical history, or personal and family history. Additionally, while suicidal ideation is currently denied, it is crucial to monitor for any changes and ensure appropriate safety measures are in place.

Diagnosis: Major depressive disorder, recurrent, severe (F33.1 ICD-10) - Active

Problem: Depressed mood

Rationale: John's depressed mood, evidenced by ongoing symptoms consistent with Major Depressive Disorder, significantly impacts his daily life and requires continued intervention.

Long-term goal: John will develop skills to recognize and manage his depression effectively.

Short-term goals and interventions:

• Maintain treatment engagement: Continue attending weekly individual therapy sessions to address negative thinking patterns, build coping mechanisms, and monitor progress.
• Optimize medication: Collaborate with the prescribing physician to continue titration of the SSRI fluoxetine as needed, ensuring optimal symptom control.
• Engage in daily physical activity: Encourage participation in structured physical activity, such as walking Jingo once a day, to improve mood and energy levels.
• Implement a safety plan: Develop a collaborative safety plan with John outlining clear steps and resources he can access in moments of suicidal ideation, ensuring his safety and well-being.

SOAP note example for psychotherapists

Stacey reports that she is 'feeling good' and enjoying her time away. Stacey reports she has been compliant with her medication and uses her meditation app whenever she feels her anxiety.

Stacey was unable to attend her session as she is on a family holiday this week. She was able to touch base with me over the phone and was willing and able to make the phone call at the set time. Stacey appeared to be calm and positive over the phone.

Stacey presented this afternoon with a relaxed mood. Her speech was normal in rate, tone, and volume. Stacey was able to articulate her thoughts and feelings coherently.

Stacey did not present with any signs of hallucinations or delusions. Insight and judgment are good. No sign of substance use was present.

Plan to meet again in person at 2 pm next Tuesday, 25th May. Stacey will continue on her current medication and has given her family copies of her safety plan should she need it.

Click here to access our SOAP Notes for Therapy Template .

SOAP note example for pediatricians

Mrs. Jones states that Julia is "doing okay." Mrs. Jones said her daughter seems to be engaging with other children in her class. Mrs. Jones said Julia is still struggling to get to sleep and that "she may need to recommence the magnesium." Despite this, Mrs. Jones states she is "not too concerned about Julia's depressive symptomatology.

Mrs. Jones thinks Julia's condition has improved.

Julia will require ongoing treatment.

Plan to meet with Julia and Mrs. Jones next week to review the treatment progress and adjust the plan as needed. Continue regular therapy sessions to support Julia's mental health and address any emerging concerns.

SOAP note example for social workers

Martin reports experiencing a worsening of his depressive symptoms, describing them as "more frequent and more intense" compared to previous experiences. He feels the depressive state is constantly present, with no improvement in anhedonia and a significant decrease in energy levels compared to the previous month. He describes feeling constantly fatigued, both mentally and physically and reports difficulty concentrating and increased irritability.

Importantly, Martin also shared experiencing daily thoughts of suicide, although he denies having a specific plan or intention to act on them.

Martin denies any hallucinations, delusions, or other psychotic-related symptomatology. His compliance with medication is good. He appears to have gained better control over his impulsive behavior as they are being observed less frequently. Martin appears to have lost weight and reports a diminished interest in food and a decreased intake.

Martin presents with significant symptoms consistent with major depressive disorder, including worsening mood, anhedonia, fatigue, difficulty concentrating, and daily thoughts of suicide. His verbal and cognitive functioning appears intact, with no signs of psychosis. He demonstrates some insight into his depression and denies any current plan or intent to act on his suicidal thoughts.

However, his nonverbal presentation paints a concerning picture, with listlessness, distractedness, slow physical movement, and depressed body language reflecting the severity of his depressive episode. It is crucial to monitor his safety closely and address the suicidal ideation with appropriate interventions despite the lack of an immediate plan.

Therefore, continuing therapy sessions with a focus on developing coping mechanisms, managing suicidal ideation, and exploring potential contributing factors is highly recommended.

Diagnosis: Major Depressive Disorder (MDD) - Active

Rationale: Martin's ongoing symptoms of depression, including daily suicidal ideation and significant functional impairment, necessitate continued intervention and support.

• Increase treatment frequency: Schedule a follow-up therapy session in two days, on Friday, May 20th, to provide immediate support and monitor safety.
• Reinforce safety plan: Review and reinforce Martin's existing safety plan , ensuring he understands and has accessible resources to address suicidal thoughts.
• Encourage communication with family: Discuss the importance of informing a trusted family member about his current state of mind and seeking their support while respecting Martin's autonomy concerning disclosure.

Additional considerations:

• Potential for medication management: Explore the potential benefits and risks of medication management, such as anti-depressants, in consultation with a physician, considering the severity and duration of symptoms.
• Collaboration with support systems: Consider involving other healthcare providers, such as Martin's primary care physician, in a coordinated care approach if deemed necessary.

SOAP note example for psychiatrists

Ms. M. describes her current state as "doing okay," with a slight improvement in her depressive symptoms. While she still experiences persistent sadness, she acknowledges slight progress. Her sleep patterns remain disrupted, although she reports improved sleep quality and gets "4 hours sleep per night."

During the session, Ms. M. expressed discomfort with my note-taking, causing her anxiety. Additionally, she mentioned occasional shortness of breath and general anxiety related to healthcare providers. Interestingly, she expressed concern about the location of her medical records.

Ms. M. is alert. Her mood is unstable but improved slightly, and she is improving her ability to regulate her emotions.

Ms. M. has a major depressive disorder.

Ms. M. will continue taking 20 milligrams of sertraline per day. If her symptoms do not improve in two weeks, the clinician will consider titrating the dose up to 40 mg. Ms. M. will continue outpatient counseling, patient education, and handouts. A comprehensive assessment and plan are to be completed by Ms. M's case manager.

The SOAP note could include data such as Ms. M's vital signs, the patient's chart, HPI, and lab work under the Objective section to monitor his medication's effects.

SOAP note example for therapists

"I'm tired of being overlooked for promotions. I don't know how to make them see what I can do." Frasier's chief complaint is feeling "misunderstood" by her colleagues.

Frasier is seated, her posture rigid, and her eye contact is minimal. She appears to be presented with a differential diagnosis.

Frasier is seeking practical ways of communicating her needs to her boss, asking for more responsibility, and how she could track her contributions.

Book a follow-up appointment. Work through some strategies to overcome communication difficulties and lack of insight. Request a physical examination from a GP or other appropriate healthcare professionals.

SOAP note example for counselors

David states that he continues to experience cravings for heroin. He desperately wants to drop out of his methadone program and revert to what he was doing. David is motivated to stay sober by his daughter and states that he is "sober but still experiencing terrible withdrawals." He stated that [he] "dreams about heroin all the time and constantly wakes in the night drenched in sweat."

David arrived promptly for his appointment, completing his patient information sheet in the waiting room while exhibiting a pleasant demeanor during the session. He displayed no signs of intoxication.

While David still exhibits heightened arousal and some distractibility, his ability to focus has improved. This was evident during his sustained engagement in a fifteen-minute discussion about his partner and his capacity for self-reflection. Additionally, David demonstrated a marked improvement in personal hygiene and self-care. His recent physical exam also revealed a weight gain of 3 pounds.

David demonstrates encouraging progress in his treatment journey. He actively utilizes coping mechanisms, ranging from control techniques to exercises, resulting in a decrease in his cravings, dropping from "constant" to "a few times an hour." This signifies his active engagement and positive response to treatment.

However, it is crucial to acknowledge that David still experiences regular cravings, indicative of his ongoing struggle. Coupled with his history of five years of heroin use, it underscores the need for further support. David would benefit from acquiring and implementing additional coping skills to consolidate his gains and progress toward sustainable recovery.

Therefore, considering both his current progress and the underlying factors related to his substance use, David would likely benefit from the addition of Cognitive Behavioral Therapy (CBT) alongside his current methadone treatment. Integrating CBT can equip him with valuable tools for managing triggers, challenging negative thoughts, and developing healthy coping mechanisms, ultimately enhancing his long-term recovery potential.

David has received a significant amount of psychoeducation within his therapy sessions. The therapist will begin to use dialectical behavioral therapy techniques to address David's emotional dysregulation. David also agreed to continue to hold family therapy sessions with his wife. Staff will continue to monitor David regularly in the interest of patient care and his past medical history.

SOAP note example for occupational therapists

Ruby stated that she feels 'energized' and 'happy.' She states that getting out of bed in the morning is markedly easier, and she feels 'motivated to find work.' She has also stated that her 'eating and sleeping have improved' but that she is concerned she is 'overeating.'

Ruby attended her session and was dressed in a matching pink tracksuit. Her personal hygiene was good, and she had taken great care to apply her makeup and paint her nails. Ruby appeared fresh and lively. Her compliance with her medication is good, and she has been able to complete her jobseekers form.

Ruby presented this morning with markedly improved affect and mood. Her speech was normal in rate and pitch and appeared to flow easily. Her thoughts were coherent, and her conversation was appropriate. Ruby's appearance and posture were different from those in our last session. Ruby's medication appears to be significantly assisting her mental health.

• Follow-up appointment: Schedule a follow-up session with Ruby in one week to monitor her progress and address any emerging concerns.
• Open communication: Encourage Ruby to maintain open communication with me and contact me for any assistance or questions regarding her job search process. This fosters a collaborative approach and ensures timely support.
• Medication adherence: Collaborate with Ruby to ensure continued adherence to her prescribed medication regimen, emphasizing its importance in managing her condition.
• Multidisciplinary team (MDT) review: Share this latest session's information with Dr. Smith for review within the MDT meeting. This facilitates collaborative analysis, discussion of potential diagnoses, and formulation of a comprehensive treatment plan.
• Exploring potential vocational support: Depending on Ruby's needs and the MDT's recommendations, exploring additional vocational support services might prove beneficial. These could include career counseling, interview preparation workshops, or specialized job search resources tailored to her specific situation.
• Addressing underlying factors: Further assessment is essential to identify any underlying factors contributing to Ruby's presentation, such as anxiety or depression, that might require additional interventions tailored to address them.

Click here to see our SOAP Notes For Occupational Therapy Template .

SOAP note example for dentists

Chief complaint: A 56-year-old woman presents with a chief complaint of "painful upper right back jaw for the past week or so."

History of present illness: The client reports experiencing pain in her upper right back jaw for approximately one week. She describes the pain as [insert patient's description of the pain, e.g., sharp, dull, throbbing, aching]. She states that the pain is [insert patient's description of pain characteristics, e.g., constant, intermittent, worse with specific activities]. She denies any history of fever, chills, facial swelling, difficulty swallowing, or earache.

Past medical history: The patient denies any significant past medical history.

Medications: The patient denies taking any current medications.

Allergies: The patient reports an allergy to paracetamol.

Social history: The patient reports a history of [insert details of tobacco use, e.g., smoking cigarettes for 30 years, one pack per day] and [insert details of alcohol consumption, e.g., occasional social drinking].

• Blood pressure: 133/91 mmHg
• Heart rate: 87 beats per minute
• Temperature: 98.7 °F (37.1 °C)

Clinical Examination:

• No signs of swelling, asymmetry, pain, redness (erythema), numbness (paraesthesia), or tenderness to palpation (TMI) were observed in the external facial and jaw areas.
• Tooth #17 (FDI #27) is supra-erupted and contacting (occluding) the pericoronal tissues (gum tissue surrounding the crown) of tooth #16.
• Red, inflamed gum tissue (erythematous gingiva)
• Presence of discharge (exudate)
• Pain upon palpation
• Pending - X-rays (including periapical (PA) and panoramic (Pano) views, or possibly a CT scan) are recommended to further evaluate the underlying anatomy and identify any potential bone involvement.
• Partial eruption of the tooth
• Inflamed gum tissue (erythema)
• Discharge (exudate) around the tooth
• Supra-eruption of the opposing tooth (#17) and its contact with the affected tissue
• Contributing factors: While a definitive cause cannot be established without further investigation, the patient's smoking history (one pack per week) could potentially contribute to the development of pericoronitis by compromising the immune response and increasing the risk of infection.
• Additional considerations: Further information is necessary to fully understand the underlying factors. Pending X-rays (PA and panoramic) will provide valuable insights into the bone structure and identify any potential complications, such as impaction or bone loss.

Therefore, a definitive diagnosis and comprehensive treatment plan will be determined following the completion of the X-ray studies and considering the patient's full medical history and any additional information gathered.

• Pain management: OTC pain meds (consider allergy) & warm compresses (10-15 min, several times/day).
• Definitive treatment: Schedule extraction of #17 after X-ray review.
• Antibiotics (pending): Consider a 5-7 day course of amoxicillin based on X-ray and severity.
• Follow-up: See patient in 3-5 days (healing, post-op concerns, oral hygiene).
• Oral hygiene education: Instruct on proper brushing/flossing and gentle cleaning of affected area.
• Smoking cessation: Encourage quitting to improve healing and reduce infection risk.

Click here to see our SOAP Notes for Dental Template .

SOAP note example for speech therapists

Jenny's mother stated, "Jenny's teacher can understand her better now." Jenny's mother is "stoked with Jenny's progress" and can "see that the improvement is helpful for Jenny's confidence."

Jenny was able to produce /I/ in the final position of words with 80% accuracy.

Jenny's pronunciation has improved by 20% since the last session with visual cues of tongue placement. Jenny has made marked improvements throughout the previous 3 sessions.

Jenny continues to improve with /I/ in the final position and is reaching the goal of /I/ in the initial position. Our next session will focus on discharge.

SOAP note example for physical therapists  

At the time of the initial assessment, Bobby complained of dull aching in his upper back at a level of 3-4 on a scale of 10. Bobby stated that the "pain increases at the end of the day to a 6 or 7." Bobby confirmed that he uses heat at home and finds that a "heat pack helps a lot."

The cervical spine range of motion is within the functional limit, with pain to the upper thoracic with flexion and extension. Cervical spine strength is 4/5. The right lateral upper extremity range of motion is within the functional limit, and strength is 5/5. Palpation is positive over paraspinal muscles at the level of C6 through to T4, with the right side being less than the left. The sensation is within normal limits.

Bobby is suffering from pain in the upper thoracic back.

To meet with Bobby on a weekly basis for modalities, including moist heat packs, ultrasound, and therapeutic exercises. The goal will be to decrease pain to a 0 and improve functionality.

SOAP note example for medical practitioners

66-year-old Darleene presents for a follow-up appointment regarding her hypertension. She reports feeling well and denies any dizziness, headaches, or fatigue.

Medical history: Darleene has no significant past medical history beyond hypertension. Her current medication regimen consists solely of HCTZ 25mg daily.

Lifestyle: Over the past three months, Darleene has successfully lost 53 pounds by implementing a low-fat diet and incorporating daily 10-minute walks. Notably, she also acknowledges consuming two glasses of wine nightly. Darleene denies using any over-the-counter medications like cold remedies or herbal supplements.

Vital signs:

• BP: 153/80 mmHg
• Pulse: 76 beats per minute
• Weight: 155 lbs
• Height: 55 inches
• General appearance: Well-nourished, no acute distress.
• HEENT: Normocephalic, atraumatic, atraumatic, atraumatic (head, eyes, ears, nose, throat - all normal).
• Neck: Supple, no jugular venous distention (JVD).
• Lungs: Clear to auscultation bilaterally.
• Heart: Regular rate and rhythm, no murmurs.
• Abdomen: Soft, non-tender, no organomegaly.
• Extremities: No edema.

Darleene is here to follow up on her hypertension. It is not well-controlled since blood pressure exceeds the goal of 135/85. A possible trigger to her poor control of HTN may be her alcohol use or the presence of obesity.

1. Lifestyle modifications

• Continue a low-fat diet and exercise: Encourage Darleene to maintain her current healthy diet.
• Increase physical activity: To further support weight loss and overall health, I recommend gradually increasing walking duration to 20-30 minutes daily.
• Moderate alcohol intake: Discuss the potential negative impact of excessive alcohol consumption on blood pressure control. Darleene agrees to limit her wine intake to weekend evenings only as a trial to assess its effect on her BP.

2. Monitoring and follow-up

• Home blood pressure (BP) monitoring: Instruct Darleene to monitor her BP regularly at home and maintain a diary to document the readings.
• Potassium level check: Schedule a blood test to assess her potassium level due to the potential electrolyte imbalance associated with diuretic use.
• Follow-up appointment: Schedule a follow-up clinic visit in one month. At this visit, Darleene should bring her BP diary for review. Based on her progress, blood pressure readings, and overall evaluation, the addition of an ACE inhibitor medication might be considered if BP remains uncontrolled.

SOAP note example for massage therapists

Fred stated that it had been about one month since his last treatment. Fred stated that he "has been spending a lot more time on his computer" and attributes the increased tension in his upper back and neck to this. Currently, Fred experiences a dull aching 4/10 in his left trapezius area. He "would like a relaxation massage focusing on my neck and shoulders."

Tenderness at the left superior angle of the scapula. Gross BUE and cervical strength. A full body massage was provided. TrPs at right upper traps and scapula. Provided client with education on posture when at the computer. Issued handouts and instructed on exercises. All treatment was kept within Pt.

Fred reported 1/10 pain following treatment. Good understanding, return demonstration of stretches and exercises—no adverse reactions to treatment.

To continue DT and TRP work on the upper back and neck as required. Reassess posture and sitting at the next visit.

Click here to see our SOAP Notes for Massage Therapy Template .

Benefits of SOAP notes

SOAP notes immensely benefit professional health clinicians within the healthcare business space. Many online healthcare platforms, such as Carepatron, offer an integrated workplace to store SOAP note documentation. In addition to this, many platforms like Carepatron also offer SOAP templates from which to work to make this process easier. This is highly beneficial considering that SOAP notes are:

• Easy to understand: Because of the SOAP formatting, they are easy for all healthcare professionals to read and are primarily used in healthcare facilities. 
• Easy to interpret: Because of their professional approach, SOAP notes clearly outline the process from observation to the treatment plan.
• Provide both subjective and objective perspectives: Allow the client to voice their experience, as well as use the scientific method to confirm what is seen.
• Allows for compliance: As a documentation method, SOAP notes enable medical professionals to be held accountable for their healthcare practices, which avoids and reduces the misinterpretation and misconstruing of information. 

SOAP note downloadable templates

Now you know the benefits of using a SOAP note template, here are some downloadable options for you to choose from in terms of SOAP note writing:

• SOAP Progress Notes Template : This SOAP Progress Notes Template separates the page into four relevant sections so you can lay out your information appropriately. 
• SOAP Notes for Physical Therapy Template :  Perfect for physical therapists and massage therapists, this SOAP note template includes a body diagram so practitioners can be as specific as possible with their information.

Why go digital with SOAP Notes?

The healthcare landscape is changing, and technology offers clinicians exciting options. Software specifically designed for SOAP medical notes simplifies documentation, improves efficiency, and offers several key benefits:

• Effortless templates: Access and customize pre-built SOAP templates to save time and ensure consistent formatting.
• Secure storage: Ditch overflowing cabinets! SOAP note software offers secure, cloud-based storage solutions, keeping patient records readily accessible.
• Streamlined compliance: Navigate HIPAA regulations with confidence. The right software handles data security and privacy protocols for you.
• Time savings: Focus on what matters most—your patients. Streamline documentation and free up valuable time for patient care.

By adopting SOAP note software, you can modernize your practice, enhance efficiency, and ultimately, prioritize patient care.

Top 5 software solutions to write SOAP Notes

Many different software options are available for healthcare practitioners, and sometimes, it can be hard to know where to look. We've done some research and identified what we think to be the top 5 software solutions for writing SOAP notes. 

1. Carepatron

Carepatron  is our number one when it comes to healthcare software. Integrated with extensive progress note templates, clinical documentation resources, and storage capabilities, Carepatron is your one-stop shop. 

The platform offers additional practice management software tools, including:

• Appointment scheduling
• Appointment reminders
• Medical billing
• Client portal
• Dictation software

And most importantly, everything is HIPAA-compliant!

Carepatron has a free plan that is perfect for smaller businesses or start-up practices. If you want additional features, the professional plan is $12/month, and the organization plan is $19/month. 

2. TherapyNotes

TherapyNotes  is a platform that offers healthcare practitioners documentation templates, including SOAP. The system integrates with a documentation library, allowing clinicians to store all their progress notes safely. Due to its practical progress note tools, TherapyNotes facilitates effective communication and coordination of care across a client's providers. 

• Solo Plan: $49/month
• Group Plan: $59/month for the first clinician and $30 per month per additional clinician

3. TheraNest

TheraNest's  software gives clinicians unlimited group and individual therapy note templates. These notes are customizable and integrated with helpful tools like drop-down bars and DSM 5 codes.

• Up to 30 clients: $42/month
• Up to 40 clients: $54/month
• Up to 50 clients: $65/month
• Up to 80 clients: $98/month

Tebra is a widespread practice management software integrated with SOAP note templates. It allows clinicians to streamline documentation with valuable features, including autosave and drop-down options. If you are interested in pricing, you should contact Tebra directly. 

5. SimplePractice

SimplePractice is our final recommendation for documentation software. It offers a comprehensive selection of fully customizable note templates. Integrated with Wiley Treatment Planners, the platform allows you to choose from a wide range of pre-written treatment goals, objectives, and interventions. 

• Starter plan: $29/month
• Essential plan: $69/month
• Plus plan: $99/month

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• TemplateLab

40 Fantastic SOAP Note Examples & Templates

If you have worked or are currently working in a hospital, you probably already know what a SOAP note is. If not, let’s learn all about it. SOAP notes are written documentation made during the course of treatment of a patient. A SOAP note template comes in a very structured format though it is only one of the numerous formats health or medical professionals can use. A SOAP note template by a nurse practitioner or any other person who works with the patient enters it into the patient’s medical records in order to update them.

It can also be used to communicate any data to other health care providers in case they don’t get a chance to speak verbally. It is essential as proof that the patient is being treated regularly and effectively by different people.

Table of Contents

• 1 SOAP Note Examples
• 2 A Short History of Soap Notes
• 3 The Benefits of Writing SOAP Notes
• 4 SOAP Note Format
• 5.1 Subjective
• 5.2 Objective
• 5.3 Assessment
• 6 SOAP Note Templates
• 8 How to Write SOAP Notes or SOAP Note Templates 
• 9 Sample SOAP Note

SOAP is actually an acronym and it stands for:

• S ubjective – This basically refers to everything the patient has to say about the issue, concern, problem and intervention procedures.
• O bjective – This, on the other hand, refers to what the health professionals have observed and what their treatments or intervention procedures are.
• A ssessment – This refers to the analysis of the health care providers regarding the different components involved in the assessment.
• P lan – This refers to the procedures which will be involved in order to successfully treat the patient or reach whatever objectives have been set at the beginning.

These also happen to be the different components of SOAP notes, which we will be discussing further in this article. SOAP notes are a type of documentation which, when used, help generate an organized and standard method for documenting any patient data. Any type of health professionals can use a SOAP note template – nurse practitioners, nurses, counselors, physicians, and of course, doctors. Using these kinds of notes allows the main health care provider to collect information about a patient from different sources, ensuring that the treatment procedures are accurate.

In this article, you will learn everything you need to know about SOAP notes – from the history, benefits, components to tips and steps in writing it yourself. First, let’s discuss a short history of SOAP notes and how they came to be.

SOAP Note Examples

A Short History of Soap Notes

SOAP notes have been around for some time now and because of their efficiency and functionality, they are still being used now. The very first SOAP note template was created and developed by a brilliant doctor named Lawrence Weed way back in the 1960s. It was done at the University of Vermont as an element of the POMR (Problem-Oriented Medical Record). During those times, objective documentation did not exist so physicians had the tendency to make decisions about treating patients without scientific basis.

With SOAP notes, each note was made and connected with a concern which had been identified by the main physician, so it served as only one element in the whole recording process. However, because of the organized format of SOAP notes, a lot of other disciplines started to use it over the POMR, and so it gradually gained popularity.

SOAP notes gave doctors, physicians and other health professionals a way to communicate with each other using a structured and organized format. Early in the 1970s, those who had begun using these notes were able to retrieve patient information and patient records and use them for reference for other similar medical problems.

The structured and organized feature of SOAP notes made documentation and communication a lot easier and now, more modern methods are still deriving a lot of their aspects from the simple SOAP notes. Now, these are very common and are being used and practiced all over the world.

The history is short and sweet, but the benefits and sustainability is another story. In the next section, we will be discussing the different benefits of writing SOAP notes to record pertinent data about a patient.

The Benefits of Writing SOAP Notes

As you’ve seen from the introduction and the history, a lot of people can write a SOAP note template, nurse practitioners, doctors, nurses and other health care providers in charge of treating patients. It is very beneficial to write down notes to keep track of and record the progress of treatments of patients.

Here are the different benefits of writing SOAP notes:

• It would serve as an important part of the treatment you had provided to a patient. It is an official document which is to be added to the records of patients. Having these notes would prove that there had been regular patient contact throughout the whole treatment period and the stay of the patient in the hospital.
• It would serve as evidence of your ability and skill to adhere to hospital practices and guidelines. After you’ve administered treatment to a patient, writing a note about it would inform other physicians that you were able to competently help the patient. On the side of the patient and the family as well, you’d have concrete proof to show them in case they have any questions about the treatment.
• It also serves as a record or documentation that quality care had been consistently given throughout the whole course of treatment of the patient. This is especially important for patients who have very sensitive or complicated concerns. Documenting everything which had been done and every step which had been taken would be the most effective way for all health care providers involved to communicate with each other and keep each other updated on the status of the patient.
• It may serve as a validation of your treatment procedures in the long run. Nowadays, a variety of illnesses and health problems are emerging and when you document all the treatment procedures you have used on patients – whether successful or not, you can use these records as a reference for when you encounter the same problems or similar issues with patients. When you have been able to successfully administer treatment to a patient, you can make a note of that to remind yourself and inform other practitioners as well.
• Written and narrative notes are the oldest and most enduring method for documentation so chances are, the majority of health professionals are familiar with them. Though there are different formats for documentation, SOAP notes are the most organized, structured and easy to understand.
• Though structured, SOAP notes are also quite flexible in the sense that they can be used in a variety of clinical settings. This method of documentation would give an overview or an overall picture of whatever treatment or patient care was given over a period of time. It can also be easily combined with other documentation methods such as patient’s medical records to form a more comprehensive document regarding the patient.

As you can see, these benefits are good not only for patients but all other health care professionals involved. This is because it paves the way for them to be able to communicate effectively while keeping track of the whole process of treatment of a patient. Now let’s move on to the different components of a SOAP note template. Knowing these would allow you to get a better feel of how to write your own notes.

SOAP Note Format

Components of SOAP Notes

Knowing the brief history and many benefits of making SOAP notes has probably made you more interested in learning even more about them. As previously stated, SOAP is actually an acronym which refers to the different components which must be present when writing it. These components can be worded in different ways as long as you follow the format and make sure that what you are writing signifies the essence of each and every one of the components.

Here are the four major components which are found in a typical SOAP note:

The subjective component of the note would describe the recent condition of the patient, written in a narrative form. The major complaint of the patient would be written here and could be worded using the patient’s own words. This component mainly focuses on the reason why the patient came to the hospital or to the doctor in the first place. It could include (but doesn’t have to be limited to):

• The onset of the injury or illness. The patient would have to give the exact date when the symptoms have started or at least a good estimate date.
• A chronology of events of the illness. This would include when the patient first began to experience symptoms, when it got worse, if any relief was felt and such, all the way up to the point when the patient had gone to the hospital.
• Specific body parts which are affected in the complaint. The pain may be concentrated in a specific area or there may be a pain in different parts of the body. The patient would have to specify all these.
• The description of the illness or what the patient is feeling. The quality and severity of symptoms are included here so that the attending physician could evaluate the patient better.
• Factors which had affected the patient or changed the quality or severity of the symptoms. Some examples of this would be if the patient felt better after taking certain medicines if the patient feels better or worse when in certain positions and other such factors.
• Any other symptoms which are significant, though may seem unrelated to the main complaint. These may help in determining what is wrong with the patient.
• Treatment which may have been given to the patient prior to the hospital visit. The patient may have already gone to a different institution or consulted with a different physician. This needs to be clarified so that the current health professional can communicate with the previous one if the need arises.

The objective component of the note would be a factual account of the patient and the patient’s status. This is a more objective look at the whole condition of the patient along with a record of the initial findings which have been made about the patient. This information can include (but not necessarily limited to) the following:

• A record of the initial vital signs taken from the patient as well as any findings or results from preliminary physical examinations. This would include the patient’s posture, any wounds or bruising, visible injuries, high temperature or any other abnormalities which are found in the patient.
• Physical measurements such as the weight and height of the patient.
• Any and all results taken from laboratory examinations, whether stool, urine or blood .
• The physician’s observation regarding the reactions of the patient while being treated. This could be in the form of nervousness, flinching, grimacing or any other indicators which may signal a deeper issue.
• Objective statements, findings, and observations which correspond with the previous component. The subjective and objective components have to tie in with each other and not have any radical differences.

This component would contain the initial diagnosis of the physician based on the first two components. The main purpose of the patient’s medical visit is to seek treatment and so the assessment should contain all the symptoms stated by the patient along with the diagnosis of the illness or injury.

It should also include a differential diagnosis or a list of other likely findings, arranged in order of the most likely one to the least likely one. This would ensure that all possibilities are considered and nothing is overlooked. The assessment could also contain all the possible causes of the patient’s problem, especially if the patient is experiencing an illness.

If the patient had made a visit before, it should also contain the progress which had been made since the last visit as well as the overall progress towards fully treating the symptoms, based on the perspective of the main physician.

Any drug related issues or drug induced issues should also be included along with any evidence and reason behind it. The pharmacist can be the one to write a note about this. Any other risk factors, evaluation for therapy options should be included as well in order to make a detailed and comprehensive assessment.

This final component should contain whatever plan or process the physician will be doing to treat the patient and eliminate any health problems or concerns. If needed, further laboratory examinations can be done along with other examinations such as a radiological procedure.

Referrals to specialists can also be given, crucial procedures may be performed and medication (along with the supplemental education) can also be given to treat a patient. All these must be included in this component of the note.

If any kind of therapy is involved, the goals of the therapy should be specified along with any drugs which will be administered throughout the course of the therapy.

A plan must be made for each and every item in the differential diagnosis especially if the patient has more than one problem with his/her health. The plan would then specify which concern is to be addressed and treated first, based on the severity of the illness or concern.

Usually, the Assessment and Plan components are grouped together to make things a lot easier. A problem is stated alongside the treatment for it. These essential components must be present in all SOAP notes so that they are effective and can be added to the medical record of the patient. Now that you know all about SOAP notes, let’s move on to the most important part – actually writing your notes. You have to know how to efficiently write SOAP notes so that you are able to provide the relevant information to inform other physicians and ultimately help the patient as well.

SOAP Note Templates

How to Write SOAP Notes or SOAP Note Templates  

Creating a SOAP note template is quite easy as long as you make yourself familiar with the different components as these would provide you with the framework for the note. If you are working in the medical field, it would be very useful for you to know how to write SOAP notes. Read on and be guided by these easy steps and tips:

• Fill in the subjective component of the note. You can get all the information you need in this portion from the patient. This would be the whole history of the patient’s complaints along with all the issues or concerns he/she has.
• The patient would be talking to you so be sure to know what questions to ask in order to make a great narrative for the subjective component of your note. The history of the patient’s injuries or illnesses is very important as you will be using it to complete the next part and component of the note.
• Avoid asking questions which would only lead to “yes or no” answers as you would not get the information needed.
• When you’ve completed the subjective portion, go on to writing the objective part of your note. This would contain what you as a physician or health professional has observed from the patient.
• While you are asking questions, you would also be examining the patient and making observations about the patient’s behavior. You may ask for examinations to be given, such as laboratory examinations if you feel that there is a need for it.
• Narrow down the injuries and probable illnesses by evaluating the symptoms and checking the results of the examinations you have made.
• Record and document all the assessments you have made based on your objective reports. Make a list of diagnoses and arrange them according to possible likelihood until you reach a diagnosis which you are sure of.
• Make sure to record any and all possibilities so you don’t miss out on anything. As you progress, you will be able to rule out other diagnoses until you’re left with the actual cause of the illness.
• Write down your plan of action and all the treatments you plan to give to the patient. Specify the treatments, therapies, and drugs – never assume that other physicians would know what you’ve written about.
• Be sure to make a fully detailed plan as it will be used as a reference for daily treatments and procedures.

Sample SOAP Note

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Guide to Writing a SOAP Note and Differential Diagnoses for an iHuman Case

• On April 24, 2024
• In Case Study Help

An iHuman case study presents a unique challenge as it deals with a simulated patient, often lacking the typical medical history and physical exam findings. However, by focusing on the presenting complaint and available data, you can still create a comprehensive SOAP note and differential diagnoses.

Table of Contents

A SOAP note is a structured format commonly used in healthcare documentation. It stands for:

• S (Subjective):  Patient’s history in their own words.
• O (Objective):  Clinical findings from physical exam and investigations.
• A (Assessment):  Analysis of the data and formulation of a working diagnosis.
• P (Plan):  Recommendations for further evaluation, treatment, and education.

Differential Diagnoses

A differential diagnosis is a list of potential illnesses that could explain the patient’s symptoms.

Guide for SOAP Note and Differential Diagnoses iHuman Cases

S (subjective).

• Include any relevant details like duration, severity, and aggravating/relieving factors.
• Since it’s an iHuman case, you won’t have a direct patient interview. However, consider any information provided about the iHuman’s programmed responses or behavior related to the complaint.

O (Objective)

• Include relevant data like vital signs, simulated physical exam findings (if available), and any diagnostic test results presented in the case.

A (Assessment)

• Consider the presenting complaint, available findings, and pathophysiology of potential diagnoses.
• Formulate a working diagnosis, the most likely explanation for the iHuman’s condition based on the available data.
• In an iHuman case, this might include recommendations for further virtual investigations within the simulation or consulting external resources for similar cases.
• Consider potential treatment options if applicable within the simulation environment.
• Also, include any educational points relevant to the iHuman’s condition.
• Briefly explain why each diagnosis is included or ruled out based on the information available.

SOAP Note and Differential Diagnoses for iHuman Case Example

iHuman “Alex” reports experiencing sudden, sharp pain in his lower right abdomen for the past two hours. The pain is intense and constant, radiating slightly towards his back. He denies any nausea, vomiting, or fever. Alex has no significant past medical history and takes no medications.

SOAP Note Example:

• Presenting Complaint:  Sudden, sharp pain in the lower right abdomen for the past two hours.
• Location:  Lower right abdomen, radiating slightly to the back.
• Onset:  Two hours ago.
• Characteristics:  Sharp, constant pain.
• Associated Symptoms:  None (nausea, vomiting, fever denied).
• Past Medical History:  Not significant.
• Medications:  None.
• Vital Signs:  Not available in this case scenario.
• Physical Exam:  Due to the iHuman nature, a physical exam cannot be performed.
• Based on the presenting complaint of sudden, sharp right lower abdominal pain, the most likely working diagnosis is  acute appendicitis .
• Appendicitis is inflammation of the appendix, a small organ located in the lower right abdomen.
• The pain typically starts around the navel and migrates to the lower right quadrant as inflammation progresses.
• The absence of nausea, vomiting, and fever in this case is less typical but not completely uncommon in presentations of appendicitis.
• Due to the limitations of the iHuman case study, further virtual investigations within the simulation are recommended.
• Ideally, this would include simulated laboratory tests for inflammatory markers like C-reactive protein (CRP) and white blood cell count (WBC).
• If available, the simulation could allow exploration of potential imaging studies like an abdominal ultrasound to visualize the appendix for signs of inflammation.
• Consulting external resources for similar iHuman cases with appendicitis presentations could also be helpful.
• If the suspicion for appendicitis remains high, the plan would involve referral for a surgical consultation within the simulation environment.
• Right ovarian cyst rupture (if Alex is a female iHuman):  This can cause sudden sharp pain in the lower right abdomen. However, it is less likely in this case due to the absence of associated symptoms like pelvic pressure or vaginal bleeding.
• Kidney stones:  Pain from kidney stones can sometimes radiate to the lower abdomen and back. However, the pain is often described as colicky (coming and going in waves) rather than constant, and may be accompanied by urinary urgency or blood in the urine.
• Urinary tract infection (UTI):  While UTIs can cause lower abdominal pain, it is typically accompanied by burning urination and urinary frequency.
• Musculoskeletal strain:  Pain from a strained muscle in the lower abdomen is possible, but the sudden onset and radiating character make it less likely.

Must Read: SOAP Note for Carolyn Cross Example

FAQ: SOAP Note and Differential Diagnoses for iHuman Cases

Welcome to i-humancasestudyanswers.com, your one-stop resource for acing iHuman case studies! This FAQ dives into the world of SOAP notes and differential diagnoses, equipping you to tackle these essential aspects of your iHuman case analysis.

What is a SOAP Note?

A SOAP note is a structured format used in healthcare documentation. It stands for: S (Subjective):  Patient’s history in their own words (modified for iHuman cases). O (Objective):  Clinical findings from physical exam and investigations (adapted for iHuman data). A (Assessment):  Analysis of the data and formulation of a working diagnosis. P (Plan):  Recommendations for further evaluation, treatment, and education (applicable within the iHuman simulation).

Why are Differential Diagnoses Important?

A differential diagnosis is a list of potential illnesses that could explain the patient’s (iHuman’s) symptoms. It helps ensure you consider various possibilities and narrow down the most likely cause based on available information.

How do I Write a SOAP Note for an iHuman Case?

Here’s a breakdown: S (Subjective):  Focus on the presenting complaint and any details provided about the iHuman’s programmed responses or behavior related to the issue. O (Objective):  Include relevant data from the case, like vital signs (if available), simulated exam findings, and test results. A (Assessment):  Analyze the S and O sections. Consider potential diagnoses, their pathophysiology, and how they fit the iHuman’s presentation. Formulate a working diagnosis. P (Plan):  Recommend further investigations within the simulation (virtual tests, consulting similar cases). Include potential treatment options (applicable within the simulation) and relevant education for the iHuman.

What are some Tips for Writing a SOAP Note and Differential Diagnoses?

Use clear, concise language with a professional tone. Include relevant medical terminology where appropriate. Tailor the depth to the complexity of the case scenario. Reference our comprehensive iHuman case study help at i-humancasestudyanswers.com for in-depth guidance and examples!

Still have questions?

Feel free to browse our website, i-humancasestudyanswers.com, for a wealth of resources on iHuman case studies, including SOAP note examples, differential diagnoses guidance, and much more. We’re here to help you conquer your iHuman cases!

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Community Health Worker Curriculum

Documentation skills for chws: writing useful case notes.

At the end of this unit, participants will be able to:

• Create documentation using the SOAP note format
• Identify the purpose and common elements of good case notes
• Identify the challenges associated with completing case notes in an effective manner
• Identify best practices and what you as a CHW bring to the process
• Practice writing a progress note based on a case study

DOWNLOAD MATERIALS:

Lesson plan and handouts (PDF)

PowerPoint slides (PPT)

50+ SOAP Note Examples, 2 Templates and Format Guide for 2024

Rachel andel rn, bsn.

• May 25, 2023
• Nursing Writing Guides

SOAP NOTE EXAMPLES, TEMPLATES and FORMAT GUIDE

As you work on becoming a skilled healthcare professionals, one critical skill that you need to acquire is documenting patient information accurately and comprehensively. 

SOAP NOTES short for Subjective, Objective, Assessment, and Plan, are a fundamental tool in healthcare documentation.

These notes serve as a crucial communication tool among healthcare providers, ensuring continuity of care and patient safety.

In this comprehensive guide, we will delve into the intricacies of creating effective soap notes tailored for nursing students.

What are SOAP NOTES

Definition of soap notes.

A soap note is a clinical method used by healthcare practitioners to simplify and organize a patient’s information.

Healthcare practitioners use the SOAP note format to record information in a consistent and structured way. 

Importance of SOAP notes in healthcare settings

Before delving into the specifics of creating a soap note, it’s essential to understand their purpose. Soap notes are a structured format for documenting patient information. They serve several key functions:

• Organized documentation process
• Communication: Soap notes provide a standardized method for healthcare professionals to communicate with each other about a patient’s condition, progress, and treatment plan.
• Legal Protection: They serve as a legal record of the care provided to a patient, which can be vital in case of disputes or legal issues.
• Continuity of Care: Soap notes ensure that different healthcare providers can understand and continue the patient’s care seamlessly.
• Monitoring and Evaluation: These notes enable healthcare providers to track a patient’s progress over time and adjust their treatment plan as needed.
• Facilitation of patient care continuity

Elements of SOAP Notes and How to Write them

The elements of a SOAP note are:

• Subjective (S): focuses on the patient’s information, experience and perceptions of symptoms, needs, and progress toward treatment goals.
• Objective (O): documents observable, objective data (“facts”) regarding the patient, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
• Assessment (A):  Includes the clinician’s assessment of the available subjective and objective information. The assessment summarizes the client’s status and progress toward treatment plan goals.
• Plan (P):  Records the actions to be taken due to the clinician’s assessment of the member’s current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.

SOAP Note Format Guide for 2024

Subjective section.

In the soap note subjective data section, includes what the patient tells you, but organize the information as a clinician

• Patient Initials: _____  Age: _______ Gender: ______
• Chief Complaint (CC):  In just a few words, explain why the patient came to the clinic. (You can use the patients words and quote them) for instance
• History of Present Illness (HPI):  This is the symptom analysis section of your note. Thorough documentation in this section is essential for  patient care , coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the  7 attributes of each principal symptom
• Quantity or severity
• Timing, including onset, duration, and frequency
• Setting in which it occurs
• Factors that have aggravated or relieved the symptom
• Associated manifestations
• Medications:  Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
• Allergies:  Include specific reactions to medications, foods, insects, and environmental factors.
• Past Medical History (PMH):  Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
• Past Surgical History (PSH):  Include dates, indications, and types of operations.
• Sexual/Reproductive History: If applicable,  include obstetric history, menstrual history, methods of contraception, and sexual function.
• Personal/Social History:  Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
• Immunization History:  Include last Tdp, Flu, pneumonia, etc.
• Significant Family History:  Include history of parents, Grandparents, siblings, and children.
• Lifestyle:  Include cultural factors, economic factors, safety, and support systems.
• Review of Systems:  From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).

Find more examples of subjective soap notes

Objective section

In the objective section, you document measurable and observable data gathered during the physical examination or diagnostic tests. This should be concrete and based on your professional assessment. Key tips for this section include:

• Use Precise Language: Describe findings using medical terminology and avoid vague terms.
• Include Vital Signs: Record the patient’s vital signs, such as blood pressure, heart rate, respiratory rate, and temperature.
• Note Objective Findings: Document physical exam findings, laboratory results, and diagnostic test results.
• This is the measurable and observable data gathered during the physical examination or diagnostic tests.
• This should be concrete and based on your professional assessment.
• Both subjective and objective sections of the SOAP note guide the collection of data from the patient.

The documentation of objective data includes;

• General:  Include any recent weight changes, weakness, fatigue, or fever, but  do not restate HPI data here .
• Respiratory
• Cardiovascular/Peripheral Vascular
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Psychiatric
• Neurological
• Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
• Hematologic:
• Allergic/Immunologic:

Assessment section (A)

The assessment section is where you, as the nursing student, provide your professional analysis and interpretation of the subjective and objective data. In this section:

• Identify Nursing Diagnoses: Formulate nursing diagnoses based on the data you’ve collected.
• Prioritize Problems: Determine which issues are most critical and require immediate attention.
• Include Patient Goals: Set measurable goals for the patient’s care and recovery.
• Entails analysis and interpretation of the subjective and objective data. In this section you will Identify the nursing diagnosis and differential diagnoses based on the data you’ve collected in the subjective and objective sections
• Include findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment AND include the patient’s Informed Consent Ability.

DSM5 Diagnosis: with ICD-10 codes

• Dx: –   

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Here are soap notes assessment section examples 

Plan section

The plan section outlines the healthcare provider’s intended actions for the patient’s care. It includes both short-term and long-term goals, interventions, and follow-up plans. To create an effective plan:

• Set Priorities: Arrange interventions in order of importance.
• Include Timelines: Specify when each intervention should occur.
• Involve the Patient: Consider the  patient’s preferences  and involve them in the decision-making process when appropriate.

The Plan section shows clinical reasoning and decision-making skills and includes; 

• Pharmacological plan
• non-pharmacological plan
• Educational Plan
• Referrals – Consultation/Collaboration plan
• Follow-up plan

55 SOAP Note Examples

• Comprehensive Psychiatric Soap Note Example
• Major Depressive Disorder Focused Soap Note Example
• Patient With Anxiety Soap Note-A 
• Focused Soap Note For Schizophrenia Spectrum  – Focused Soap Note For Schizophrenia Spectrum, Other Psychotic, And Medication-Induced Movement Disorders
• Focused Soap Note For Anxiety Ptsd And Ocd  – Focused Soap Note For Anxiety PTSD And OCD
• Major Depressive Disorder Focused Soap Note- and medical notes – 
• Anxiety Soap Note- -Therapy soap note examples
• Comprehensive Focused Soap Note For Schizophrenia Spectrum Other Psychotic And Medication-Induced Movement Disorders – Comprehensive Focused Soap Note For Schizophrenia Spectrum Other Psychotic And Medication-Induced Movement Disorders 
• Comprehensive Soap Note On Generalized Anxiety Disorder 
• Comprehensive Psychiatric Evaluation Soap Note On Obsessive-Compulsive Disorder-Nursing Essay Example
• Major Depressive Disorder Focused Soap Note-A  
• Patient With Anxiety Soap Note Comprehensive Nursing Paper Sample  
• Comprehensive Soap Note On Assessing And Diagnosing Patients With Mood Disorders-  
• Pediatric Soap Note Example
• PMHNP Soap Note Example
• Comprehensive ADHD Soap Note
• Initial Psychiatric Interview Soap Note
• Clinical Soap Note On Psychiatric Progress Note  
• Clinical Follow-Up Soap Note For A Psychiatric Patient 
• Soap Note For A Suicide Assessment Of A Client With Initially Subtle Warnings Of Suicide-Shelby Colatrella Case Study  
• Moderate Alcohol Use Disorder Comprehensive Soap Note Example  
• Clinical Soap Note On Obsessive-Compulsive Disorder  
• Obsessive-Compulsive Disorder Comprehensive Clinical Soap Note 
• Adjustment Disorder Soap Note 
• Soap Note On Schizophreniform Disorder
•  Week 7- Prac-6665 Focused Soap Note And Patient Case Presentation-
• Soap Note On Incarcerated Hernia 
• Clinical Soap Note For A Pediatric Patient   
• Obsessive Compulsive Disorder Clinical Soap Note
• Social Anxiety Clinical Soap Note 
• Mental Health Clinical Soap Note 
• Clinical Soap Note On Anxiety Disorder
• Episodic Soap Note Allergic Rhinitis
• Depression Focused Soap Note 
• Brian Foster Soap Note 
• Comprehensive Soap Note On Proasis 
• Tina Jones Documentation Of History And Physical Exam Soap Note 
• Focused Soap Note And Patient Case Presentation 
• Borderline Personality Disorder Focused Soap Note
• Comprehensive Soap Note On Psoriasis
• Pediatric Comprehensive Soap Note – Well Child Exam Without Abnormalities (Z00.129)
• Case Study Analysis Example With Soap Note – Genitourinary Assessment Soap Note
• Tina Jones Comprehensive Soap Note
• Unit 12 Assignment – Clinical: Soap Note
• Initial Psychiatric Interview/Soap Note – Assignment 1 Solution
• The Assignment 1: Focused Soap Note On Personality And Paraphilic Disorders 
• Soap Notes For Mental Health Professional 
• Unit 3 Soap Note – Ms. A Presents With Complaints Of Headache And General Fatigue
• Comprehensive Psychiatric Evaluation Note soap note examples to help
• Focused Soap Psychiatric Evaluation Comprehensive Nursing Paper Sample
• Unit 7 Soap: 54 Yo Female With Low Back Pain Radiating To Left Leg – Solution

SOAP Notes Templates

• Initial Psychiatric Soap Note Template
• Shadow Health Comprehensive Soap Note Template 
• 670 Case Study Psychiatric Soap Note Template With Rx  
• Tina Jones Shadow Health Soap Note Template

Tips for Effective Soap Note Documentation

Creating comprehensive and accurate soap notes can be challenging, but with practice and attention to detail, nursing students can master this essential skill. Here are some tips to help you excel in soap note documentation:

• Maintain Confidentiality – Always remember to maintain patient confidentiality. Use initials or unique identifiers instead of the patient’s full name, and store your notes securely to protect patient privacy.
• Be Concise and Clear – Avoid unnecessary jargon or acronyms that may not be familiar to all healthcare providers. Write in a clear, concise, and organized manner to ensure your notes are easy to understand.
• Use Standard Terminology – Adopt standardized medical terminology to ensure consistency and clarity in your documentation. This helps prevent misunderstandings among healthcare providers.
• Follow the Nursing Process – The nursing process involves assessment, diagnosis, planning, implementation, and evaluation (ADPIE). Apply this framework when creating your soap notes to ensure a comprehensive approach to patient care.
• Collaborate with Others – Communication is key in healthcare. Collaborate with other members of the healthcare team, such as physicians, therapists, and social workers, to gather and incorporate their input into your notes.
• Stay Up-to-Date – Medical knowledge evolves constantly. Stay updated on the latest evidence-based practices and guidelines relevant to your field of nursing to provide the best care and documentation.

How do you write a SOAP note for nursing?

Writing a SOAP note for nursing involves four key components: Subjective (patient-reported information), Objective (measurable data), Assessment (professional analysis), and Plan (care plan). Start by gathering patient information, documenting physical findings, formulating nursing diagnoses, and outlining a care plan.

What are the 4 parts of SOAP?

The four parts of SOAP are: S – Subjective: Patient-reported information. O – Objective: Measurable data. A – Assessment: Professional analysis and nursing diagnoses. P – Plan: Care plan and interventions.

What are 3 guidelines to follow when writing SOAP notes?

Three essential guidelines for writing SOAP notes are: Be concise and clear in your documentation. Use standardized medical terminology. Maintain patient confidentiality and privacy.

What is an example of a SOAP note?

Here’s a simplified example of a SOAP note: S (Subjective):  The patient reports a sore throat and difficulty swallowing. O (Objective):  Physical examination reveals redness and swelling in the throat, temperature of 100.4°F. A (Assessment):  Nursing Diagnosis – Acute Pharyngitis. P (Plan): Administer prescribed antibiotics. Encourage fluid intake and throat lozenges for comfort. Advise the patient to rest and follow up in three days for reevaluation

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What Are SOAP Notes in Counseling? (incl. Examples)

How do these professionals communicate this information with other professionals also working with the patient or client?

Years ago, this type of communication was not easy. It often meant that a client had to remember from visit to visit what they said to one doctor and then to another.

Now, medical professionals use SOAP notes for this purpose. This type of note-taking system offers one clear advantage: consistent, clear information about each patient during each visit to a provider. When the providers are part of the same group, this information can be easily shared.

Before you read on, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains

What are soap notes, why are soap notes important, writing your soap notes, 2 soap note examples, 3 useful templates, a take-home message, frequently asked questions.

Professionals in the medical and psychological fields often use SOAP notes while working with patients or clients. They are an easy-to-understand process of capturing the critical points during an interaction. Coaches also can make use of SOAP notes, with some adaptations.

SOAP notes are structured and ordered so that only vital and pertinent information is included. Initially developed by Larry Weed 50 years ago, these notes provide a “ framework for evaluating information [and a] cognitive framework for clinical reasoning ” (Gossman, Lew, & Ghassemzadeh, 2020).

SOAP notes are primarily the realm of medical professionals; however, as you continue reading, you will see examples of how you might adapt them for use in a coaching session.

To begin, the acronym SOAP stands for the following components:

During the first part of the interaction, the client or patient explains their chief complaint (CC). There might be more than one, so it is the professional’s role to listen and ask clarifying questions . These questions help to write the subjective and objective portions of the notes accurately.

The descriptor ‘subjective’ comes from the client’s perspective regarding their experiences and feelings. It might also include the view of others who are close to the client.

An example of a subjective note could be, “ Client has headaches. Client expressed concern about inability to stay focused and achieve goals .”

Another useful acronym for capturing subjective information is OLDCARTS (Gossman et al., 2020).

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
• Alleviating and aggravating factors : What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least severe, 10 being the most severe, how does the patient rate the CC?

Think back to when you have had an appointment with a doctor. How many of these questions did your doctor ask? Chances are, they asked all of them. These questions are part of the initial intake of information and help the doctor or therapist assess, diagnose, and create a treatment plan.

A coach can easily adapt this method to their sessions and exclude whatever does not apply.

For example, a life coach may not need to know or ask about location unless the client indicates that every time they are in a particular spot, they notice X. Here, the idea is shifted from a location in the body to a location in the environment.

The professional only includes information that is tangible in this section. In a clinical setting, this might be details about:

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Recognition and review of the documentation of other clinicians

Some clinical examples include, “ Patients heart rate is X .” “ Upon examination of the patient’s eyes, it was found that they are unable to read lines X and X .”

In a coaching situation, a coach might include some of this information, but it depends on why the client is seeking assistance from the coach and the type of coaching. For instance, a health or fitness coach might want to note diagnostic details like vital signs before, during, and after exercise.

Most coaches do not talk in terms of symptoms or signs, but if you happen to do so, then it is important to understand the distinction between them.

Symptoms are what the person tells you is going on physically, psychologically, and emotionally. They are the client’s subjective opinion and should be included in the “S” part of your notes.

Signs are objective information related to the symptoms the client expressed and are included in the “O” section of your notes.

Using the example from earlier, a coach might determine that the “S” is the client expressing concern over an inability to complete tasks and achieve a larger goal. The “O” is their observation that the client has no time-keeping devices.

After further discussion, the coach may discover that the client does not plan their day with any structured tool. They use sticky notes as reminders. Each of these small details might relate to the CC: an inability to stay focused and complete goals.

On the other hand, a medical doctor would assess the headache issue and test the person’s eyesight, especially if the patient does not already wear glasses.

The doctor might also explore whether the patient has attention deficit-hyperactivity disorder because the CC mentions “an inability to focus and achieve goals.”

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In this section, the professional combines what they know from both the subjective and objective information. Here, the therapist or doctor identifies the primary problem, along with any contributing factors.

They also analyze the interaction between problems, as well as any changes. When finished, the clinician has a diagnosis of the problem, a differential diagnosis (other possible explanations), discussion, and a plan.

Coaches do not “diagnose” in the traditional sense. Their role is generally one of assisting a client in seeing what they typically already know, but with greater clarity and, perhaps, renewed purpose.

A plan is where the rubber meets the road. Working with the client or patient, the clinician creates a plan going forward. The plan might include additional testing, medications, and the implementation of various activities (e.g., counseling, therapy, dietary and exercise changes, meditation.)

In a coaching relationship, the coach works with the client to create realistic goals, including incremental steps. This plan includes check-in points and deadlines for each smaller goal and the larger one. The coach might assign homework just as a therapist would. Often the homework offers opportunities for self-reflection. It also provides practice and acquisition of a new skill.

There are other considerations and inclusions used in the medical field. Gossman et al. (2020) also point out several limitations regarding the use of SOAP notes, including:

• The order places the less essential details at the top. It forces the clinician to lose time scanning for necessary information during subsequent visits.
• There is no section addressing how conditions change over time.
• There also is no assessment area for how the plan is working.

At the 2016 NCRG Conference on Gambling and Addiction, she covered SOAP notes and the elements of good documentation.

According to Tuohy (2016), good documentation includes:

• Use of direct quotes from the patient or client
• A distinction between facts, observations, hard data, and opinions
• Information written in present tense, as appropriate
• Internal consistency
• Relevant information with appropriate details
• Notes that are organized, concise, and reflect the application of professional knowledge

SOAP notes offer concrete, clear language and avoid the use of professional jargon. They include descriptions using the five senses, as appropriate. They also avoid value-heavy terms. Impressions made by the clinician are labeled as such and based on observable data. Written documentation is about gathering the facts, not evaluating them.

Documentation protects the medical and therapeutic professionals while also helping the client. Clear notes communicate all necessary information about the patient or client to all of the people involved in the person’s care. SOAP notes facilitate the coordination and continuity of care.

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The primary thing to keep in mind is that SOAP notes are meant to be detailed, but not lengthy. They are a clear and concise record of each interaction with the patient or client.

Following the format is essential, but it is possible to reorder it so that the assessment and plan appear at the top (APSO). Doing this makes it much easier to locate the information you might need during future meetings or appointments.

The following video by Jessica Nishikawa provides additional information regarding why SOAP notes are used, by whom, and how.

Your client Tom Peters met with you this morning. Your notes are as follows:

S: “ They don’t appreciate how hard I’m working .” O: Client did not sit down when he entered. Client is pacing with his hands clenched. Client sat and is fidgeting. Client is crumpling a sheet of paper. A: Needs ideas for better communicating with their boss; Needs ideas for stress management. P: Practice conflict resolution scenarios; Practice body scan technique; Go for a walk during lunch every day for one week.

Your client Rosy Storme met with you this afternoon.

S: “ I’m tired of being overlooked for promotions. I just don’t know how to make them see what I can do .” O: Client is sitting in a chair, slumped forward, and burying her face in her hands. A: Needs ideas for better communicating her ideas with her boss; Needs ideas for how to ask for more responsibility; Needs ideas for tracking her contributions. P: Practice asking for what you want scenarios; Volunteer for roles within the company that are unrelated to current job; Brainstorm solutions to problems employer faces.

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Numerous websites offer free SOAP templates. Most are designed for use in the medical professions, including client-centered therapy and counseling. Here are three templates you can use for a medical visit, therapy, or coaching session.

1. SOAP note for medical practitioners (Care Cloud, n.d.):

2. SOAP note for counseling sessions (PDF)

3. SOAP note for coaching sessions (PDF)

Whether you are in the medical, therapy, counseling, or coaching profession , SOAP notes are an excellent way to document interactions with patients or clients. SOAP notes are easy to use and designed to communicate the most relevant information about the individual. They can also provide documentation of progress.

For clinical professionals, SOAP notes offer a clear, concise picture of where the client is at the time of each session. They contribute to the continuity of care and are a tool for risk management and malpractice protection. For the client, they provide documentation of their problem, diagnosis, treatment options, and plans.

What is your experience using SOAP notes? How have you applied them to your coaching practice?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

SOAP is a commonly used method for organizing and documenting clinical notes in medical settings. It stands for

• Subjective,
• Assessment, and

A SOAP note is usually structured in this order;

• subjective refers to information provided from the client’s perspective,
• objective refers to measurable or observable information about the client,
• assessment refers to a healthcare provider’s assessment of the subjective and objective information, and
• plan refers to the proposed treatment by the healthcare provider.

There are five types of SOAP notes, including

• Comprehensive,
• Problem-Oriented, and

Simple SOAP notes contain the basic four sections of Subjective, Objective, Assessment, and Plan. Extended SOAP notes expand on the Simple format by adding additional sections.

• Care Cloud (n.d.) Free SOAP note template. Retrieved March 6, 2020, from https://www.carecloud.com/continuum/free-soap-note-template/
• Gossman, W., Lew, V, & Ghassemzadeh, S. (2020, September 3). SOAP notes. StatPearls Publishing. Retrieved March 6, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK482263/
• Nishikawa, J. (2015, October 17). SOAP notes [Video]. YouTube. https://youtu.be/9TZqTtbBVXc
• Tuohy, C. M. (2016, September 25–26). Foundations of addiction treatment [Conference session]. 17th Annual NCRG Conference on Gambling and Addiction, Las Vegas, NV.

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What our readers think.

Please I need more samples of clinical soap Note to serve as a guide to me. This is because I need to complete my practicum clinicals. Thank you so much and awaiting your response and help

You’ll find even more SOAP note templates here: https://templatelab.com/soap-note-examples/

Hope this helps!

– Nicole | Community Manager

Wonderful, SOAP notes indeed will help me a student counselor and as a beginner, I will be guided by this acronym so that l will be able offer assistance to my clients. I will be guided by it in my counselling sessions.

I am currently a student working on my degree in Mental Health Counseling. The example provided above is a great example and has help me to understand the dynamic of a SOAP note. Thank you!

I am a student at the University of Maine Augusta. This is required reading for my case management course. It is very helpful. Thank-you.

I like this!

Thanks for sharing this resource! I have heard of SOAP notes from a “scriptures study” practice, and have been using it in my own learning – e.g. I read a chapter in a book and reflect on it – What did it SAY? What did I OBSERVE from that? How does it APPLY to my life now? What’s a PRACTICE I want to put in place now. This gives me a whole new way to look at it in my coaching practice. Thank you.

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3 Perfect Nurse Practitioner SOAP Note Examples + How to Write

As a nurse practitioner, you understand the importance of timely, accurate documentation . There are many types of documentation and formats you can follow when documenting, and one of the most common is the SOAP note. If you are serious about creating good documentation, you may wonder, “Who can tell me exactly how to write a nurse practitioner soap note?” NP soap notes should have four essential components and follow the SOAP format. In this article, I will share 3 perfect nurse practitioner SOAP note examples + how to write them. Although nurses have different ways of documenting, if you follow the SOAP format and include the required components, you should be able to create an NP SOAP note that is relevant to all members of the healthcare team.

What is a Nurse Practitioner Soap Note?

What is the purpose of writing a nurse practitioner soap note, what components should be included in np soap notes, component #1: subjective data, component #2: objective data, component #3: assessment, component #4: plan of care, how to write a nurse practitioner soap note, step #1: gather subjective data by interviewing the patient, step #2: review the patient’s chart and any test results for objective data, step #3: perform an assessment to obtain additional objective information, step #4: determine differential diagnoses, step #5: document your final diagnosis, step #6: create a plan of care and record it in the soap note, what are the perfect examples of nurse practitioner soap notes.

My Final Thoughts

Frequently asked questions answered by our expert, 1. who can write np soap notes, 2. when to write np soap notes, 3. ideally, how long should np soap notes be, 4. what’s the most important part of np soap note, 5. can i use abbreviations in np soap notes, 6. what tense do i write np soap notes, 7. are np soap notes handwritten or printed, 8. how to sign off np soap notes.