SOAP Notes Examples & Templates 

If you are in healthcare or worked in medical sphere   SOAP notes must be a familiar term for you. Patient care and treatment become easier and more convenient, all thanks to the soap notes. 

With SOAP notes, documenting patient information becomes simple and structured rather than confusing. This standardized method helps physicians, nurses, therapists, and other healthcare providers capture essential details with clarity and precision. 

Let’s first understand briefly the term SOAP notes and its significance: 

To put it in few words it is a methodical approach of recording patient data that is divided into Subjective, Objective, Assessment, and Plan is known as SOAP notes. Its importance stems from the fact that it makes medical records straightforward, well-structured, and simple for any physician to follow. Effective communication, patient progress tracking, and continuity of treatment are all made possible by SOAP notes, which ultimately improve patient outcomes and facilitate teamwork in clinical settings. 

In this blog, you’ll find sample SOAP notes from various specialties, along with customizable templates you can adapt to your own practice. Whether you’re just starting out or have years of experience, these examples highlight how SOAP notes improve documentation, strengthen communication, and ensure patient care remains consistent and effective. 

SOAP Note Example 1: Medical (General Practice) 

Subjective (S): The patient reports having a headache that is usually worse in the evening and has lasted for three days. They deny feeling lightheaded, nauseated, or having blurred vision. 

The objective (O) is to record the blood pressure at 140/90 mmHg and the pulse rate at 84 bpm. A neurological evaluation reveals no indications of deficiencies or anomalies. 

Assessment (A): Results point to a tension headache, although consideration should be given to consequences from hypertension. 

Plan (P): Give the patient advice on stress management strategies and a prescription for a moderate analgesic to relieve symptoms. Schedule a follow-up in a week and keep a regular check on your blood pressure. 

Example 2:  Nursing SOAP Format 

Subjective (S): After surgery, the patient states that their pain level is a 7 out of 10. To feel more at ease, they communicate discomfort and ask for help. 

Goal (O): There is no visible drainage, the surgical site seems clean, and the dressing is still in place. Vital indicators don’t change, suggesting that there are no problems right now. 

Assessment (A): There is no sign of infection, although the patient is having post-operative pain. At this point, the overall rate of recuperation seems normal. 

Plan (P): Give the patient the prescribed painkiller to control their pain, and after an hour, gauge their degree of comfort again. To promote relaxation and recuperation, promote deep breathing techniques. 

SOAP Note Example 3: Mental Health & Counselling 

Subjective (S): The patient reports having trouble sleeping for the previous two weeks and experiencing persistent anxiety and restlessness. Daily functioning is starting to be hampered by these symptoms. 

Goal (O): The patient is clearly agitated and fidgety throughout the session. There are no outward indications of physical sickness or urgent medical issues. 

Evaluation (A): The symptoms, which include a notable disruption in sleep, are consistent with generalized anxiety disorder. Ongoing assessment will assist track the severity and validate the diagnosis. 

Plan (P): Start holding weekly sessions of Cognitive Behavioural Therapy (CBT) and suggest stress-reduction relaxation strategies. If the patient continues to have trouble sleeping, you might want to refer them for a sleep study. 

To provide clarity and consistency in day-to-day care, SOAP notes in nursing Practice assist in the structured recording of patient symptoms, observations, and care interventions. 

By enabling nurses to systematically record evaluations and treatments, SOAP nursing documentation enhances communication with the medical staff and promotes continuity of patient care. 

Physical Therapy as an Example of a SOAP Note 

Subjective (S): The patient states that weight-bearing activities or stair climbing exacerbate left knee pain. Over time, they observe that the soreness has been progressively getting worse. 

The examination indicates a 15-degree decrease in range of motion and moderate edema surrounding the knee joint (O). There is no visible redness or severe damage. 

Assessment (A): Signs point to a potential early recurrence of left knee osteoarthritis. Targeted treatment and more observation are advised. 

Plan (P): Give instructions for knee-strengthening activities and suggest using ice after working out. Make an appointment for a follow-up in two weeks to evaluate your progress. 

Daily Use SOAP Note Template 

Subjective (S): The patient’s viewpoint, including complaints, symptoms, and medical history, is captured in this section. What the patient says about their illness is reflected in it. 

Goal (O): Documents quantifiable and visible information, including vital signs, test results, or physical examination findings. It serves as the assessment’s factual foundation. 

Assessment (A): To arrive at a diagnostic or clinical impression, the healthcare professional analyses the objective and subjective data. Differential diagnoses could be part of it as well. 

Plan (P): Describes the course of treatment, including any prescription drugs, therapies, follow-up appointments, or recommendations. It guarantees the patient’s next steps and continuity of care. 

Why using SOAP note templates is beneficial: 

Saves time by offering a pre-made framework, freeing up professionals to concentrate on content rather than formatting. 

Ensures uniformity by standardizing documents among various departments and vendors. 

Lowers Errors: This lowers the possibility of overlooking crucial information when evaluating patients. 

Enhances Communication: Facilitates understanding and adherence to patient records by a few healthcare personnel. 

Promotes Legal Compliance: Assists in keeping thorough and accurate records for medicolegal and auditing purposes. 

Improves Training: Assists new practitioners and students in forming appropriate documentation practices. 

Enhances Patient Care: Better treatment planning and results are achieved when clarity and continuity are ensured. 

Conclusion: 

To sum up, SOAP notes are essential to efficient healthcare recording since they offer uniformity, clarity, and structure for all specialties. Professionals may save time, minimize mistakes, and guarantee smooth communication among care teams with the use of real-world examples and customizable templates. SOAP notes are an essential tool in contemporary healthcare since they can significantly improve patient care and expedite clinical workflows, regardless of whether you’re a student learning the fundamentals or an experienced clinician honing your craft.