8 Essential SOAP Note Example Templates for 2025

In modern healthcare, clear and concise clinical documentation is the backbone of excellent patient care, seamless team collaboration, and accurate billing. The SOAP note, standing for Subjective, Objective, Assessment, and Plan, remains the gold standard format. A well-written note tells a compelling patient story, justifies clinical decisions, and outlines a clear path forward.

Yet, clinicians often struggle with finding the right balance between detail and brevity, leading to documentation fatigue and potential errors. A powerful SOAP note is more than just a template; it's a direct reflection of your thought process. At the heart of effective SOAP note documentation lies the ability to accurately assess and plan for patient care through strong clinical reasoning skills, making the practice of mastering clinical reasoning a critical component of high-quality documentation.

This guide moves beyond theory to provide practical, high-quality examples you can use today. We have curated 8 meticulously crafted SOAP note example templates, each designed for a specific and common clinical scenario, from the emergency department to outpatient primary care. We will break down the strategic elements of each soap note example, offering actionable insights and replicable methods to elevate your documentation skills.

Furthermore, we'll explore how leveraging advanced tools like Simbie AI can streamline this entire process. These systems can transform lengthy dictation and typing into structured, accurate notes almost instantly. This automation allows you to focus more on direct patient care and less on the administrative burden of paperwork, ultimately improving both efficiency and the quality of your clinical records.

1. Emergency Department SOAP Note – Acute Myocardial Infarction

In the high-stakes environment of the Emergency Department (ED), a SOAP note for a suspected acute myocardial infarction (AMI) must be a model of clarity, precision, and speed. This type of note prioritizes rapid assessment and critical data to support time-sensitive interventions like thrombolysis or percutaneous coronary intervention (PCI). The structure is designed to quickly communicate the patient's status, key diagnostic findings, and the immediate treatment plan, making it an essential SOAP note example for any acute care setting.

Strategic Breakdown

The core strategy behind an ED AMI note is "time is muscle." Every entry serves to justify and document rapid, life-saving care. The subjective section captures the exact time of symptom onset, which is critical for determining treatment eligibility. The objective section highlights vital signs, EKG interpretations (e.g., "ST-elevation in leads II, III, aVF"), and initial troponin levels, providing a clear, evidence-based picture of an active cardiac event.

Key Insight: For an AMI, the SOAP note is more than documentation; it's a real-time clinical tool. It tracks progress against critical time-based metrics, such as a 45-minute door-to-balloon time for a STEMI patient, directly influencing patient outcomes and fulfilling quality reporting requirements.

Actionable Takeaways & Best Practices

To optimize your ED notes for cardiac emergencies, focus on efficiency and clarity.

• Document Critical Times: Always record the time of symptom onset, patient arrival, EKG acquisition, and cardiology consultation. This creates an unambiguous timeline for clinical decision-making and review.
• Be Specific with Data: Instead of "chest pain," write "substernal, crushing chest pain, 8/10 severity, radiating to the left arm." Instead of "abnormal EKG," specify the findings, such as "acute anterolateral STEMI."
• Incorporate Risk Factors: The Assessment section should briefly list relevant cardiac risk factors (e.g., hypertension, diabetes, smoking history) to strengthen the clinical impression and justify the plan. For an in-depth look at various note structures, explore these essential medical report formats.
• Leverage Technology: Using EMR templates with built-in macros or voice-powered AI tools like Simbie AI can drastically reduce documentation time, allowing you to focus on the patient while ensuring all critical data points are captured accurately.

2. Outpatient Primary Care SOAP Note – Type 2 Diabetes Management

In the primary care setting, a SOAP note for chronic disease management, like Type 2 Diabetes, shifts from acute intervention to longitudinal care. This note is less about a single event and more about telling a story over time. It documents ongoing assessment, medication adjustments, patient education, and progress toward long-term health goals, making it a quintessential soap note example for managing chronic conditions that require consistent follow-up and care coordination.

Strategic Breakdown

The core strategy for a diabetes management note is demonstrating continuity of care and medical necessity. The subjective section captures the patient's self-reported glucose readings, adherence to diet and medication, and any new symptoms like neuropathy or vision changes. The objective section focuses on trends, comparing current vital signs, weight, and lab values (especially HbA1c) to previous results to build a clear clinical picture over months or years.

Key Insight: This type of SOAP note serves as a crucial legal and billing document that justifies the level of care provided. It meticulously tracks progress against established goals (e.g., HbA1c <7%), documents medication changes with clear rationale, and records patient education, which is essential for meeting quality metrics and supporting higher-level E/M codes.

Actionable Takeaways & Best Practices

To create effective and efficient primary care notes for chronic diseases, focus on clarity, goal-setting, and structured data.

• Document Quantifiable Goals: The Assessment and Plan sections should clearly state specific, measurable targets. For instance, "Goal: HbA1c <7.0%, BP <130/80 mmHg." This frames the entire visit around actionable health outcomes.
• Track Lab Trends: Instead of just listing the current HbA1c, write "HbA1c is 8.2%, up from 7.5% three months prior, indicating worsening glycemic control." This provides immediate context for your assessment and plan.
• Be Specific with Patient Education: Document what was discussed. For example, "Educated patient on carbohydrate counting and the importance of foot self-exams for 10 minutes." This proves active management and patient engagement. If you need a solid foundation, you can get started with this free SOAP note template.
• Use Smart Templates: For common conditions like diabetes, EMR templates or AI-powered tools like Simbie AI can pre-populate relevant fields, allowing you to focus on the patient's unique circumstances while ensuring all necessary data points are captured consistently and accurately for every visit.

3. Mental Health/Psychiatry SOAP Note – Major Depressive Disorder Initial Evaluation

A psychiatric SOAP note, especially for an initial evaluation of Major Depressive Disorder (MDD), is a nuanced document that blends clinical observation with narrative history. It goes beyond physical symptoms to capture the patient's internal experience, psychosocial context, and functional impairment. This detailed SOAP note example is crucial for establishing an accurate diagnosis using DSM-5 criteria, assessing risk, and formulating a comprehensive, patient-centered treatment plan that may include both psychotherapy and psychopharmacology.

Strategic Breakdown

The core strategy for a psychiatric SOAP note is "biopsychosocial formulation." The note must weave together biological factors (family history, medical conditions), psychological elements (thought patterns, mood, trauma history), and social determinants (support systems, stressors, cultural background) into a cohesive clinical picture. The Subjective section is expanded to include a detailed history of present illness and psychiatric review of systems, while the Objective section features a thorough Mental Status Exam (MSE). The Assessment is not just a diagnosis but a synthesis of all these elements, explaining why the patient meets the criteria for MDD.

Key Insight: In mental health, risk assessment is paramount. The note must explicitly document the presence or absence of suicidal and homicidal ideation, intent, and plan. Using a structured tool like the Columbia-Suicide Severity Rating Scale (C-SSRS) provides a standardized, defensible record of this critical evaluation, which is essential for ensuring patient safety and managing liability.

Actionable Takeaways & Best Practices

To create effective and defensible psychiatric notes, focus on detail, structure, and risk documentation.

• Quote the Patient: In the MSE, use direct patient quotes to illustrate their mood, affect, and thought content. For example, instead of "depressed mood," write "Patient states, ‘I feel like there’s a black cloud over me that I can't escape.’"
• Use Standardized Tools: Document the use of validated screening tools like the PHQ-9 for depression severity or the GAD-7 for anxiety. Note the scores in the Objective section to quantify symptoms and track progress over time.
• Be Specific About Risk: Clearly document your risk assessment. For instance, "Patient denies suicidal ideation, intent, or plan. Has protective factors including strong family support and future-oriented goals." If you're seeking to refine this documentation process, understanding how to write progress notes effectively is a key first step.
• Integrate Technology: The detailed narrative required in psychiatry can be time-consuming. Voice-powered AI tools like Simbie AI can help capture complex patient stories and structured MSE findings efficiently, ensuring your documentation is both comprehensive and completed in a timely manner.

4. Orthopedic/Physical Medicine SOAP Note – Anterior Knee Pain Syndrome

In orthopedics and physical medicine, a SOAP note for a condition like anterior knee pain syndrome must be detailed, functional, and precise. This note goes beyond subjective pain, documenting the specific mechanism of injury, functional limitations, and objective physical exam findings. The structure is built to track progress over time, justify rehabilitation plans, and clearly communicate the patient's musculoskeletal status, making it a crucial SOAP note example for any practitioner managing joint and muscle conditions.

Strategic Breakdown

The core strategy for an orthopedic SOAP note is "function follows form." Every entry is designed to connect anatomical findings to the patient's functional capacity. The subjective section details how the pain impacts daily activities, like "difficulty descending stairs." The objective section provides quantifiable data, such as goniometric range of motion (ROM) measurements, manual muscle testing grades, and the results of special orthopedic tests (e.g., "Positive Patellar Grind Test"), painting a clear picture of the physical impairment.

Key Insight: For musculoskeletal issues, the Assessment section is not just a diagnosis but a clinical synthesis. It should include a primary diagnosis supported by a list of differential diagnoses (e.g., patellofemoral pain syndrome vs. patellar tendonitis), which justifies the comprehensive treatment plan and demonstrates thorough clinical reasoning for billing and reimbursement purposes.

Actionable Takeaways & Best Practices

To create effective orthopedic notes, focus on specificity and standardized terminology.

• Quantify Everything Possible: Document ROM in degrees (e.g., "Knee Flexion AROM: 0-120°"). Measure swelling with circumferential measurements at set landmarks. Use a 0-10 pain scale tied to specific movements like squatting or lunging.
• Use Standardized Test Names: Clearly state the results of special tests using accepted nomenclature, such as "Lachman's test negative for ACL laxity" or "McMurray's test positive for medial meniscal pathology." This ensures universal understanding among specialists.
• Detail the Rehabilitation Plan: The Plan should be highly specific, outlining frequency of physical therapy, home exercise programs (e.g., "quad sets 3×10 daily"), and a clear timeline for return-to-activity goals.
• Integrate EMR Efficiencies: Utilize EMR templates with built-in orthopedic tests and diagrams to quickly document findings. Voice-powered tools like Simbie AI can help capture detailed narrative descriptions of gait or movement patterns during the exam, ensuring no critical detail is lost.

5. Obstetric SOAP Note – Third Trimester Prenatal Visit

In obstetrics, the third-trimester prenatal SOAP note is a critical tool for monitoring the health of both the expectant mother and the developing fetus as delivery approaches. This note meticulously tracks key indicators of well-being, screens for late-onset complications, and documents essential patient education. The structure is designed to provide a clear, longitudinal record that supports clinical decisions, ensuring a safe transition from pregnancy to birth, making it a vital SOAP note example for OB/GYN, midwifery, and family medicine settings.

Strategic Breakdown

The core strategy of a third-trimester OB note is proactive surveillance and anticipatory guidance. Each component is forward-looking, aiming to identify potential issues like preeclampsia or fetal growth restriction before they become emergencies. The Subjective section captures the patient's report of fetal movement and any warning signs (e.g., contractions, leakage of fluid). The Objective section provides a quantitative snapshot of progress, documenting fundal height, fetal heart tones, maternal vital signs, and recent lab results, creating a clear evidence base for continued low-risk care or the need for intervention.

Key Insight: This SOAP note functions as a safety checklist and a communication tool. It ensures all ACOG-recommended assessments are completed and documents the crucial conversations about labor signs, birth plans, and postpartum care. This creates a defensible record and empowers the patient with the information needed for the final weeks of pregnancy.

Actionable Takeaways & Best Practices

To enhance your obstetric documentation, focus on precision and patient-centered planning.

• Standardize Fetal Assessment: Always document fundal height in centimeters and compare it to the gestational age. Record the specific fetal heart rate range (e.g., "FHT 140s bpm") rather than just "positive." Explicitly note that fetal movement is "reassuring" or "per patient report."
• Be Explicit with Screenings: Clearly state the results of key third-trimester screenings, such as the glucose tolerance test (GTT) for gestational diabetes and Group B Streptococcus (GBS) swab status.
• Detail Anticipatory Guidance: The Plan section should go beyond "return in one week." Document the specific topics discussed, such as "Reviewed signs of labor," "Discussed pain management options," and "Provided breastfeeding resources."
• Utilize EMR Efficiencies: Leverage EMR templates with built-in fields for fundal height, fetal presentation (e.g., vertex, breech), and GBS status. Voice-to-text tools like Simbie AI can help capture detailed patient education discussions efficiently, ensuring your notes are both comprehensive and completed in a timely manner.

6. Pediatric SOAP Note – Acute Otitis Media

Documenting a pediatric visit for acute otitis media (AOM) requires a unique approach that blends parental reporting with objective clinical findings. This type of note must capture specific details relevant to the patient's age and developmental stage, such as non-verbal signs of pain and precise fever characteristics. The structure is tailored to justify treatment decisions, particularly the use of antibiotics, in line with established guidelines like those from the American Academy of Pediatrics (AAP). This makes it a crucial soap note example for anyone in family medicine, pediatrics, or urgent care.

Strategic Breakdown

The strategy for a pediatric AOM note centers on guideline-driven decision-making and parental education. The subjective section is vital, as it often relies on a caregiver's report. Capturing phrases like "tugging at left ear" or "more irritable than usual, especially when lying down" provides essential context for a non-verbal child. The objective section must contain a detailed description of the otoscopic exam, noting tympanic membrane (TM) color, position (e.g., bulging), and mobility to confirm the diagnosis. The assessment and plan must then explicitly link these findings to the treatment choice.

Key Insight: The pediatric AOM note serves a dual purpose: it documents the clinical encounter and acts as a tool for antibiotic stewardship. By clearly outlining the criteria met for AOM diagnosis and the rationale for either prescribing antibiotics or choosing watchful waiting, the note demonstrates adherence to best practices and supports public health goals of reducing antibiotic resistance.

Actionable Takeaways & Best Practices

To create effective and defensible pediatric AOM notes, focus on precision and clear justification.

• Document Specific Fever History: Record the onset, maximum temperature, method of measurement (e.g., temporal, rectal), and any antipyretics used. This detail helps establish the severity and timeline of the illness.
• Use Age-Appropriate Descriptors: For the subjective history, quote or paraphrase the caregiver's description of symptoms, such as "pulling at ears," "inconsolable crying," or "poor feeding," which are often more telling than a simple complaint of pain.
• Be Objective with Otoscopic Findings: Clearly describe the TM's appearance, including erythema, bulging, landmarks (obscured or visible), and presence of effusion or purulence. This is the cornerstone of the AOM diagnosis.
• Justify Antibiotic Choices: In the Plan section, explicitly state why a specific antibiotic was chosen (e.g., "Amoxicillin as first-line therapy per AAP guidelines") or why watchful waiting is appropriate (e.g., "Patient over 2 years old with non-severe, unilateral AOM").
• Automate to Focus on Care: Pediatric visits can be fast-paced. Using an EMR with pediatric templates or an AI-powered scribe like Simbie AI allows you to capture detailed parental histories and objective findings in real-time, ensuring documentation is thorough without taking focus away from the child and their caregiver.

7. Oncology SOAP Note – Chemotherapy Toxicity Management

In oncology, the SOAP note is a critical tool for tracking a patient's journey through treatment, focusing meticulously on their tolerance to chemotherapy and the management of side effects. This specialized note documents subtle and significant changes in a patient's condition, from performance status to specific toxicities like nausea, neuropathy, or bone marrow suppression. This detailed approach makes it an essential SOAP note example for managing complex, longitudinal patient care where treatment plans are frequently adjusted based on patient response.

Strategic Breakdown

The strategy for an oncology SOAP note is proactive toxicity management. The goal is to identify, grade, and mitigate side effects early to maintain the patient's quality of life and ensure they can complete their prescribed treatment regimen. The subjective section captures the patient's experience of symptoms at home, while the objective portion provides hard data from lab work (CBC, metabolic panels) and physical exams. This structured data allows for precise, evidence-based decisions, such as dose reductions or adding supportive medications.

Key Insight: In oncology documentation, standardized grading is paramount. Using the Common Terminology Criteria for Adverse Events (CTCAE) scale provides a universal language to describe the severity of side effects. A note stating "Grade 2 peripheral neuropathy" is immediately understood by any oncologist, ensuring clear communication and consistent care across the healthcare team.

Actionable Takeaways & Best Practices

To create effective and defensible oncology notes, focus on standardization and clear justification.

• Use CTCAE Grading: Consistently grade all toxicities (e.g., nausea, fatigue, neuropathy) using the standard Grade 1-5 scale. This objective measure is crucial for justifying treatment modifications.
• Document Key Labs: Always include the absolute neutrophil count (ANC), platelet count, and hemoglobin levels. Explicitly link these values to your decisions, such as "Holding chemotherapy due to ANC of 0.8."
• Justify All Plan Changes: Clearly state the clinical reasoning for any deviation from the standard treatment plan. For example, "Reducing oxaliplatin dose by 25% due to worsening Grade 2 neuropathy, as per patient report and physical exam." Understanding these nuances is part of the essential strategies for managing chemotherapy side effects.
• Streamline with Templates: EMR templates designed for specific chemotherapy regimens can auto-populate common side effects and lab parameters. Pairing these with voice AI tools like Simbie AI allows you to dictate findings and assessments quickly, ensuring comprehensive documentation without sacrificing valuable clinic time.

8. Home Health/Skilled Nursing Facility SOAP Note – Post-Operative Hip Fracture Recovery

In post-acute settings like a Skilled Nursing Facility (SNF) or during home health visits, the SOAP note serves a different, more longitudinal purpose compared to acute care. For a patient recovering from a hip fracture, the note tracks the journey from dependence to functional independence, focusing on rehabilitation progress, pain management, and medical stability. This SOAP note example is crucial for coordinating care among nurses, therapists, and physicians, ensuring a safe and effective recovery trajectory.

Strategic Breakdown

The strategy for this note is "Continuity and Functional Progression." It moves beyond the immediate crisis to document the day-to-day and week-to-week recovery. The subjective section captures the patient's reported pain levels, mood, and perceived progress, while the objective section quantifies this with concrete data: wound status, range of motion measurements, and standardized functional scores. This dual focus ensures the plan addresses both the patient's experience and clinical realities.

Key Insight: In transitional care, the SOAP note becomes a narrative of recovery. It must clearly document the patient's adherence to precautions (e.g., weight-bearing status), response to therapy, and any barriers to discharge. This detailed tracking is essential for justifying continued skilled care under Medicare guidelines and for planning a safe transition home.

Actionable Takeaways & Best Practices

To craft effective SNF or home health notes, focus on functional milestones and interdisciplinary collaboration.

• Quantify Functional Status: Use standardized scales to track progress. Instead of "walking better," document "ambulated 30 feet with rolling walker, minimal assistance, adhering to toe-touch weight-bearing status." Reference PT/OT goals and progress toward them.
• Be Objective with Wound Assessment: Describe the surgical incision with precision. Note its length, location, and condition (e.g., "10cm surgical incision to right hip, well-approximated with staples intact, no erythema, edema, or drainage noted").
• Integrate a Multifactorial Assessment: The Assessment section should synthesize information beyond the hip itself. Address comorbidities (e.g., hypertension, diabetes), assess fall risk, and note cognitive status, as these factors heavily influence recovery and discharge planning.
• Streamline with Integrated Tools: Managing complex post-operative patients requires efficiency. Using an EMR with built-in templates or adopting a voice-enabled AI scribe like Simbie AI allows clinicians to capture detailed narrative and discrete data points simultaneously, ensuring comprehensive notes without sacrificing valuable patient-facing time.

SOAP Note Comparison: 8 Clinical Scenarios

From Templates to Transformation: Making Your Documentation Work for You

We've explored a wide range of SOAP note examples, from the high-stakes environment of an emergency department to the nuanced follow-up of primary care and mental health. Each template, whether for pediatrics or oncology, serves as more than just a documentation guide; it's a blueprint for structured clinical thinking. The true power of these examples lies not in copying them verbatim, but in understanding the strategic thinking behind their construction.

By breaking down each soap note example, we’ve revealed how a well-crafted note is a narrative of patient care. It tells a clear story, justifies clinical decisions, and creates a seamless path for continuity of care. The detailed annotations highlight how specific phrasing choices, objective data placement, and a well-reasoned assessment and plan work together to create a document that is both legally sound and clinically effective.

Key Takeaways for Immediate Application

Mastering the art of the SOAP note is a journey of continuous refinement. The goal is to move beyond simply filling out fields to creating documentation that actively supports your clinical workflow and enhances patient safety.

Here are the most critical takeaways from our analysis:

• Structure is Strategy: The S-O-A-P format is not just a tradition; it’s a logical framework that separates subjective patient experience from objective clinical findings. This separation is crucial for clear diagnostic reasoning and prevents cognitive biases from clouding your judgment.
• Precision in Phrasing Matters: As seen in the orthopedic and psychiatric examples, the difference between "patient reports feeling sad" and "patient endorses persistent anhedonia and feelings of worthlessness" is significant. Specific, professional language elevates the quality of your documentation and ensures accurate communication with other providers.
• The Plan is Your Action Blueprint: The "Plan" section is the most vital part of the note. It must directly address every problem identified in the "Assessment." A detailed plan demonstrates thoroughness and provides clear, actionable steps for the patient and the entire care team.
• Context is King: Each specialty has unique documentation demands. The pediatric note focuses on developmental context and parental concerns, while the oncology note prioritizes toxicity grading and treatment adjustments. Adapting your note structure to the clinical context is non-negotiable for effective care.

The Next Frontier: Automation and Intelligent Documentation

While mastering these templates and techniques is a significant step forward, the ultimate goal is to minimize the time spent on documentation without sacrificing quality. The manual process of typing, clicking, and navigating EMRs remains a primary driver of clinician burnout. This is where modern technology offers a transformative solution.

The principles of a great soap note example can be amplified with intelligent automation. Instead of being a barrier between you and your patient, documentation can become a seamless background process. AI-powered tools like Simbie AI are designed to listen to your natural patient conversations and instantly translate them into structured, accurate, and comprehensive SOAP notes.

This technology handles the meticulous task of capturing subjective complaints, objective findings, and detailed plans directly from the source. It eliminates the need for after-hours charting and the cognitive load of trying to recall details from a busy clinic day. By automating the creation of high-quality SOAP notes, you reclaim invaluable time to focus on what truly matters: patient connection, critical thinking, and delivering compassionate care. Adopting this technology is the final step in transforming documentation from a burden into a powerful, efficient asset.

Ready to eliminate documentation headaches and spend more time with your patients? Discover how Simbie AI uses advanced voice technology to automatically generate perfect SOAP notes from your patient conversations. Visit Simbie AI to see how you can transform your clinical workflow today.