SOAP note example: How to write SOAP notes

Clinicians: You can defuse a crisis at 10 am, soothe a patient's meltdown at 10.30, and maybe even perform a minor miracle before noon.

But having to catch up on SOAP notes after all that? Sometimes, that’s the loose thread that can unravel anyone's sanity.

The SOAP format has been a staple of clinical documentation for over 50 years, but let’s face it—writing high-quality SOAP notes isn’t always smooth sailing. Time crunches, juggling consistency, and figuring out what details matter most can leave even seasoned clinicians at a loss.

In this blog, we’ll break down real SOAP note examples and share note-taking do’s and don’ts to help you level up your documentation.

What is a SOAP note?

SOAP notes are the tried-and-true format most clinicians use to document patient exams.

SOAP stands for Subjective, Objective, Assessment, and Plan. You’ll organize your notes into these four sections  to organize your findings and recommendations.

Here’s why sticking to this structure is key to delivering effective patient care:

• Improves efficiency: Clinicians can quickly locate key information, like the patient’s reported symptoms, diagnostic findings, and care plan. Having a detailed but focused source of truth for patient interactions also ensures that legal and compliance needs are appropriately met for better auditing and billing processes.
• Supports clinical decision-making: Separating notes into clearly defined sections helps clinicians logically present their assessments and rationale. SOAP notes ultimately empower healthcare providers to take action based on clearly documented evidence.
• Enhances patient outcomes: SOAP notes create accountability on healthcare teams to build care plans that are well-documented, thorough, and actionable. It encourages comprehensiveness with a clear purpose instead of aimless lengthiness, leading to more effective treatments and follow-ups.
• Simplifies standardization: The consistency of SOAP sets it apart from other note-taking frameworks — like the Data, Assessment, Plan (DAP) format. SOAP notes are precise and methodical, while DAP notes are flexible and less centered around measurable data . If you're looking for a clear way to capture evidence-based notes for multidisciplinary patient care, then you'll benefit from how nuanced you can be when documenting patient observations.

How should you write a SOAP note?

Each section of a SOAP note has a specific purpose in helping clinicians sort their findings, data, and care recommendations.

Understanding the type of information to prioritize in each section of your SOAP note is key to ensuring the brevity and accuracy of your documentation.

Let's break down each section with examples:

Subjective

This section captures a patient’s subjective perspective about their concerns and experiences.

You’ll document the primary problem the patient is presenting, other symptoms that they’re feeling, and other relevant information like medical history or lifestyle habits that could be related to their complaint.

Examples:

• Mr. Jones' chief complaint is a back pain. He also exercises 5x a week with heavy weights.
• Angie complained of abdominal pain that has persisted for the past two days.

Objective

This section records of measurable data collected during a patient’s visit, such as physical exam results and lab tests completed during that time. Physicians will also add their observations or direct patient quotes to this section.

Examples:  

• Mr. Jones' vital signs are normal. His lower back has tenderness to palpation.
• Angie’s abdomen has no rebound tenderness in the lower right quadrant. No visible swelling or bruising.

Assessment

This section summarizes the patient’s perspectives and physician observations into a clinical diagnosis.

This section holds the most weight in your SOAP note as it describes a thorough analysis of the patient’s problems, all possible diagnoses, and the reasoning behind that diagnosis.

Examples:

• Lower back pain is a lumbar muscle strain from overexertion during heavy weightlifting. A different diagnosis could be a Vitamin D deficiency.
• Abdominal pain without signs of acute abdomen or significant palpation. Likely gastrointestinal discomfort or mild inflammation.

Plan

This section outlines the next steps in your recommended treatment plan. You’ll use this section to detail information such as action items for future examinations, required medication, or referrals for more testing or consultations with specialists.

Examples:

• Recommend avoidance of heavy lifting for one to two weeks. Prescribe a mild analgesic for pain and a diagnostic test for D3 deficiency. Schedule a follow-up appointment next week.
• Prescribe over-the-counter antacids for relief when needed. Monitor for symptoms like fever, severe pain, nausea, or vomiting.

SOAP note examples (and what you can learn from them)

The examples below will help you better visualize how healthcare providers use the SOAP template to structure and guide their clinical documentation.

Example 1: SOAP note for patient presented with abdominal pain.

What can we learn from this example?

• It provides a clear timeline with descriptions of symptoms, including patient quotes and relevant anecdotes for clarity.
• It includes vital signs and specific diagnostic indicators for a more precise diagnosis.
• The assessment is supported by clinical findings that differentiate possible conditions and reference relevant literature.
• The document includes clear next steps and provides actionable patient instructions.

Example 2: SOAP note for a patient follow-up on a chronic problem.

What can we learn from this example?

• The note is concise and avoids unnecessary details, making it easier for healthcare providers to understand the patient’s condition and care plan.
• The patient’s history, symptoms, and self-reported readings are documented because they are relevant to her diabetes management.
• The plan clearly describes ongoing management strategies and outlines appropriate follow-ups, and includes specific instructions for pre-visit lab tests.

6 tips for writing powerful SOAP notes

Beyond understanding the purpose of each SOAP section, clinicians have to approach the note-taking process with a clear understanding of how to optimize their language choices and writing styles specifically for documentation. Now that you've seen what strong clinical notes look like in action, let's review a few important reminders that reinforce the clarity, effectiveness, and overall efficiency of your note-taking.

Avoid jargon and abbreviations

Remember that the aim SOAP notes is to help your entire healthcare team ensure accuracy, drive patient care forward, and avoid miscommunication. Using universal language that multidisciplinary healthcare providers can understand is important in making your documentation readable and easy to act on.

The next provider meeting your patient may be someone outside your specialty. If that’s the case, you’ll want to:

• Do: Explain acronyms the first time you use them if you need to bring that acronym up.
• Don’t: Use shorthand commonly used in your department. For example, using “WNL” instead of “within normal limits” might be unclear to non-clinical staff.

Use concise and direct sentences

Your SOAP notes should make it easy digest highlights from your patient examination quickly.

Long sentences and big walls of text will make your notes hard to scan. If you take a look at the SOAP note examples above, you’ll notice that clinicians don’t have to write in full sentences, and bullet points are used to make their notes more skimmable.

Even when notes are written in paragraph form, these sentences are straight to the point.

• DO: Write short sentences focusing on essential information, key findings, and actions.
• DON'T: Use complex descriptions and wordy sentences to describe a patient encounter. For example — “Patient reports headache that worsens in bright light” instead of “The patient described having headaches that become more painful every time they look at something bright around the house.”

Refrain from adding excessive detail unless it’s necessary

Although adding context from patient encounters is important, you’ll also want to be mindful that the details you include are relevant to the concern you have at hand.

For example, adding information from friendly conversations with patients into your notes won’t add a clear benefit to the next step in your care plan.

Instead, it will cause clutter and make it harder to deduce essential action items. The same goes for recollections of past symptoms and medical history that aren’t relevant to the problem the patient is presenting.

• DO: Focus your notes on observations, rationales, and action related to the patient’s primary concern.
• DON'T: Include anecdotes and history unrelated to the assessment you’re trying to make. In that first SOAP note example, the patient having pasta and meatballs for dinner was important because that’s when their pain started. But you wouldn’t want to highlight what the patient watched on TV while having dinner.

Structure your SOAP notes in logical order

The SOAP structure was created to help clinicians present their findings in an organized way.

It also helps you document your observations and rationale by order of importance and relevance so that it’s easy for other healthcare providers to follow. Arranging your notes logically helps you tell your patient’s story accurately and with the right context.

• DO: Understand the requirements of each SOAP section and follow the format provided: Subjective first, followed by Objective, Assessment, and Plan.
• DON'T: Rearrange sections or blend content from different sections together.

Keep a professional and objective tone

Your clinical notes are factual documents that serve a clear purpose of helping patients get the care they need based on the concerns they’re presenting.

Your notes must remain unbiased and solely focused on the medical problem you’re trying to assess.

• DO: Use neutral language that focuses on actual observations and descriptions of the situation in front of you.
• DON'T: Make assumptions or accusations of a patient’s character or behavior based on your impression of them during an encounter. For example, a healthcare provider should not be documenting their personal opinion on unrelated lifestyle habits or health challenges.

Save time with transcription software and automation

Transcription software streamlines the documentation process and turns spoken medical dictations into written text. It saves time and effort for clinicians and medical students to create accurate and organized notes from the many patient interactions they have.

Tools like Freed go beyond traditional transcription by using generative AI to capture your virtual and office visits and automatically format them into SOAP notes. This improves the accuracy of speech-to-text while giving clinicians the ease of having editable documents in seconds.

• DO: Use transcription software to quickly capture, format, and edit your SOAP notes.
• DON'T: Rely on dated or manual transcription methods that require extensive post-dictation editing. For example, Freed allows you to generate ready-to-use notes instantly, minimizing the need for manual adjustments.

Accelerate your SOAP note-taking with Freed

By following the tips in this article, we’re excited to empower more clinicians and medical students with the support they need to create comprehensive, structured — all while saving time. Freed’s medical transcription software empowers healthcare providers with a HIPAA-compliant solution that uses AI to accurately capture medical notes and deliver customizable, ready-to-use documentation that works seamlessly with your favorite EHR systems.

With Freed’s SOAP note generator, you can get started with your note-taking automation in a matter of seconds. Try it out for free today.