Let Vero fill it in from the visit.
Vero Scribe writes the SOAP note in your template from the visit conversation, with the patient’s consent, or from your dictation. You review it, edit it, and copy it into the chart.
SOAP Note Template
A SOAP note records a visit in four parts: Subjective, Objective, Assessment, and Plan. Copy the free template, see three filled examples, and check what goes in each section.
- Free, no account needed
- Word and text downloads
- Three filled examples
Blank SOAP note template
FreeSOAP NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Visit type: [In person or telehealth; new or follow-up] Clinician: [Name, credentials] SUBJECTIVE Chief complaint: [Reason for the visit, in the patient's words] History of present illness: [Onset, location, duration, character, what makes it better or worse, timing, severity] Relevant history: [Past medical, surgical, family, and social history that bears on today's problem] Medications: [Current medications, doses, adherence] Allergies: [Drug and other allergies, with reactions] Review of systems: [Pertinent positives and negatives] OBJECTIVE Vital signs: [BP, HR, RR, temperature, SpO2, weight] Examination: [Findings by system, focused on the complaint] Results: [Labs, imaging, and other tests reviewed, with dates] ASSESSMENT Problem 1: [Diagnosis or working impression, with the findings that support it] Differential: [Other diagnoses considered, and why they are more or less likely] Status: [New, improving, stable, or worsening] PLAN Investigations: [Tests ordered] Treatment: [Medications with dose, route, and frequency; procedures; referrals] Education: [What was discussed, and the patient's understanding and agreement] Follow-up: [When, with whom, and when to return sooner] Signed: [Clinician name, credentials, date and time]
Use it for
- Primary care visits
- Follow-ups
- Telehealth
- Urgent care
- Specialist visits
Three filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
SOAP note: sore throat
Primary care, acute visit
Subjective
28-year-old with a sore throat for 3 days, worse on swallowing. Felt feverish last night, not measured. No cough, runny nose, or ear pain. Drinking fluids without difficulty. No regular medications. No known drug allergies.
Objective
T 38.4 °C (101.1 °F), HR 92, BP 118/76, RR 16, SpO2 99% on room air. Tonsils red, not enlarged, no exudate. Tender anterior cervical lymph nodes. Uvula midline; opens mouth fully. Ears normal. Chest clear. Rapid strep test negative.
Assessment
Acute pharyngitis, most likely viral. Modified Centor (McIsaac) score 3: fever, no cough, tender anterior nodes. Rapid strep test negative. No signs of peritonsillar abscess.
Plan
Supportive care: acetaminophen or ibuprofen for pain and fever, fluids, salt-water gargles. Antibiotics not indicated; reasons explained, and the patient agrees. Off work until the fever settles. Return if unable to swallow fluids, drooling, muffled voice, trouble opening the mouth, swelling on one side of the neck, or no improvement in 5 to 7 days.
SOAP note: low back pain
Primary care, new problem
Subjective
45-year-old with low back pain for 10 days after lifting boxes during a move. Aching, right-sided, not spreading below the knee. Worse bending, eases lying down. Ibuprofen helps partly. No numbness in the groin or buttocks, no bladder or bowel changes, no leg weakness, no fever, no weight loss, no history of cancer.
Objective
Afebrile. Walks without a limp. Tender right lumbar paraspinal muscles. Forward flexion limited by pain. Straight-leg raise negative on both sides. Strength, sensation, and reflexes normal in both legs.
Assessment
Acute mechanical low back pain, most likely a right lumbar muscle strain. No red flags for cauda equina syndrome, infection, fracture, or cancer, so imaging is not indicated.
Plan
Stay active and avoid bed rest. Ibuprofen with food as needed; heat. Back exercise handout given. Referral to physical therapy offered and accepted. No heavy lifting at work for 2 weeks. Seek urgent care for numbness in the groin, bladder or bowel changes, or leg weakness. Follow up in 4 weeks if not improving.
SOAP note: anxiety follow-up by video
Telehealth, follow-up visit
Subjective
Follow-up for generalized anxiety, 8 weeks after starting sertraline 50 mg daily. Worrying less and sleeping better. Mild nausea in the first 2 weeks, now gone. Taking the medication every day. Attending weekly CBT sessions. Denies thoughts of self-harm or suicide.
Objective
Video visit; patient at home, identity and location confirmed. Appears well and relaxed. Speech normal in rate and tone. Mood “much better”; affect brighter than at the last visit. GAD-7 today 8 (14 at the last visit). Vital signs not taken.
Assessment
Generalized anxiety disorder, improving on sertraline and CBT. Side effects resolved. No safety concerns today.
Plan
Continue sertraline 50 mg daily and weekly CBT. Advised not to stop the medication suddenly. Repeat GAD-7 at the next visit. Video follow-up in 6 weeks; contact the clinic sooner if symptoms get worse, and call 911 or go to the nearest emergency department for thoughts of self-harm.
What goes in each part.
Subjective
What the patient, or a family member, tells you: why they came and the story behind it.
- The chief complaint, in the patient’s words
- History of present illness: onset, location, duration, character, what makes it better or worse, timing, and severity
- Pertinent negatives that change your thinking
- Medications, allergies, and the history that bears on today’s problem
Avoid: Putting your own findings or conclusions here. Anything you examined or measured belongs in Objective.
Objective
What you observe, measure, or review: facts another clinician could check.
- Vital signs
- Examination findings, focused on the complaint
- Labs, imaging, and other results, with dates
- For telehealth, what you could see on video, with any home readings labeled as patient-reported
Avoid: Copying a full normal exam forward when you didn’t examine those systems today.
Assessment
Your clinical reasoning: what you think is going on, and why.
- The diagnosis or working impression for each problem
- The findings that support it
- The other diagnoses you considered
- Status: new, improving, stable, or worsening
Avoid: Restating the complaint (“sore throat”) instead of an impression (“viral pharyngitis, strep test negative”).
Plan
What happens next, problem by problem.
- Tests ordered
- Treatment: medications with dose, route, and frequency; procedures; referrals
- What you explained, and the patient’s agreement
- Follow-up, and when to return sooner
Avoid: Leaving out follow-up or when to return sooner. If something goes wrong, the plan is the first place anyone looks.
SOAP note templates by specialty.
The same structure, with the fields and examples each specialty documents.
Family medicine SOAP noteFor multi-problem visits: an agenda, numbered problems, health maintenance, and follow-up.Nurse practitioner SOAP noteEpisodic SOAP note with pertinent positives and negatives, a justified differential, and prescribing details.Pediatric SOAP noteThe sick-visit SOAP note for children, with caregiver history, hydration, and weight-based doses.Counseling SOAP noteSOAP for therapy sessions, with mental status observations and PHQ-9 and GAD-7 scores.Social work SOAP noteSOAP for psychosocial work: client report, observations and collateral, needs, and referrals.Physical therapy SOAP noteFollow-up visit note with pain, ROM, MMT, special tests, timed interventions, and the home program.Occupational therapy SOAP noteFunction-focused session note with ADLs, IADLs, assist levels, cues, fine motor, and safety.Speech therapy SOAP noteSLP session note with accuracy and cue levels for each goal, for articulation and aphasia.Chiropractic SOAP noteVisit note with segmental findings, adjustments by region and technique, and response to care.
Common mistakes, and how to avoid them.
Copying the last note forward
Old findings and plans carried into today’s note make it look as if you examined or decided things you didn’t. Update each section or delete it.
Mixing what was said with what was found
Keep what the patient reports apart from what you examined or measured. It shows how you reached your assessment.
An assessment that repeats the symptoms
Name your impression and the reasoning behind it, even when it is a working diagnosis.
One plan for several problems
Number each problem in the assessment and give it its own plan, so nothing is lost at the next visit.
Unclear abbreviations
Use the abbreviations your organization approves, and spell out anything another clinician could misread.
Use in Vero
Frequently asked questions.
What does SOAP stand for?
Subjective, Objective, Assessment, and Plan. Subjective is what the patient tells you, Objective is what you observe and measure, Assessment is your clinical reasoning, and Plan is what happens next.
What is the difference between subjective and objective in a SOAP note?
Subjective is what the patient or family reports, such as symptoms and history. Objective is what you can observe or check, such as vital signs, examination findings, and test results.
How long should a SOAP note be?
Long enough to support your decisions and let the next clinician pick up where you left off. A focused follow-up may need a few lines per section; a new or complex problem needs more. Leave out fields you didn’t address rather than filling them with defaults.
How do you write a SOAP note for several problems?
Keep one Subjective and one Objective section, then number the problems in the Assessment and give each a matching plan. Repeat the template’s Problem 1 line for each one.
Can I use a SOAP note for a telehealth visit?
Yes. Record that the visit was by video or phone, confirm the patient’s identity and location, and note in Objective what you could see on video and any home readings the patient reported. The anxiety follow-up above is a video visit.
Is this SOAP note template free?
Yes. Copy it, or download it as a Word or text file, with no account needed. Edit the headings and fields to fit your specialty and your organization’s requirements.
Can Vero fill in a SOAP note for me?
Yes. Vero Scribe writes the note in your template from the visit conversation, with the patient’s consent, or from your dictation. You review and edit it before it goes into the chart.
More templates, and guides.
SBAR template
Situation, Background, Assessment, Recommendation: for calls, handoffs, and transfers.
Referral letter template
To a specialist or service, with a clear question, the urgency, and the history.
How to write a SOAP note
A step-by-step guide, with a checklist and the most common mistakes.
AI SOAP notes
How Vero Scribe drafts SOAP notes from the visit for you to review.
SOAP notes for nursing
The nursing version, with SOAPIE and worked examples.
Clinical note examples
Seven worked notes in different formats, with review checks.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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