SOAP note template

A blank SOAP structure for clinical documentation: subjective, objective, assessment and plan.

How to use itUse it as a structure for each encounter, following your organization’s documentation standards. Clinical content is the responsibility of the licensed provider.

Who uses itClinicians, therapists and other licensed providers
WhenDuring or right after each encounter
Time neededA few minutes per note
Keep itYour secure record system, per privacy rules

Where the SOAP note template fits

SOAP is a widely used format for organizing clinical notes. It separates what the patient reports from what is observed, what is concluded and what will be done.

This page offers a neutral structure only. It is not clinical guidance, and your organization’s records policy, privacy rules and scope of practice apply.

16 items. Use it on screen, or print it and fill it in by hand.

Subjective

Chief complaint in the patient’s words.
History of the present concern.
Relevant history, medications and allergies.
Patient goals.

Objective

Vital signs.
Observations and examination findings.
Test results.
Measurements.

Assessment

Provider’s assessment.
Progress compared with the last visit.
Problems listed.

Plan

Using the SOAP note template well

Write the note during or soon after the encounter.
Keep subjective and objective separate.
Be specific and measurable.
Follow your organization’s abbreviations list.
Store notes in your secure record system.

The SOAP note at one business

A physical therapy note records the client’s report of knee pain on stairs (S), measured range of motion and gait observation (O), the therapist’s assessment of progress since the last visit (A), and the exercises and next appointment date (P).

What the SOAP note protects you from

Clinical notes are part of the medical record, which payers review to support billing and which HIPAA requires to be protected. A consistent SOAP structure makes it easy for another provider to see what was found and what comes next.

Filled-in sample

Practice	Northshore Speech Therapy, Evanston IL
Client and date	Ava, age 7, session 6, Oct 14
S	Parent reports fewer ‘w for r’ substitutions at home
O	/r/ in initial position 72% accurate in 25 trials, up from 58%
A	Steady progress toward 80% goal
P	Move to /r/ in phrases; home practice sheet; next session Oct 21
Signed	Megan, MS, CCC-SLP

The objective section gives a trial count and accuracy so progress can be compared with the last session. The parent’s report goes in subjective because it is reported, not measured.

Where a SOAP note usually goes wrong

Writing interpretations in the subjective section. ‘Patient anxious’ is an observation; ‘patient says she feels nervous’ is subjective.
Copying the last note forward and changing a few words. Copied text can carry old findings into today’s record.
Ending the plan without a follow-up. Even ‘return as needed’ should be written down.

Variations for different teams

Physical and occupational therapyPut measured function, such as range of motion or walking distance, in objective so progress is easy to compare.

Counseling practicesMany settings use a variant format; check your organization’s standard before adapting the sections.

Pro tipQuote the patient’s own words for the chief complaint. It keeps the note faithful and is useful when comparing visits.

Questions about the SOAP note template

What does SOAP stand for?

Subjective, objective, assessment, plan.

Who uses SOAP notes?

Many clinical and care professions.

Can I use this for pediatric notes?

Yes, adapt the prompts to your setting.

Where should notes be stored?

In a secure system that meets privacy rules.

What goes in the assessment section of a SOAP note?

The assessment is the clinician’s interpretation of the subjective and objective information: the working diagnosis or problem list, how the patient is progressing compared with the last visit and any factors affecting care. It should connect the findings to the plan. Avoid repeating data already in S and O.

How long should a SOAP note be?

Long enough that another clinician could pick up care from it, and no longer. A routine follow-up may be a few lines per section, while an initial evaluation is longer. Use specific measurements and the patient’s own words where they matter, and leave out filler.

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Disclaimer: This template is general information for organizing work. It is not medical, clinical or regulatory advice and does not replace your facility’s protocols or the requirements of health authorities. Have a qualified professional review it before use.