SOAP note template

Every section of a SOAP note and what goes in it. Print it, copy it, or use it as a checklist while you write.

Free. For practice and learning; follow your program's and facility's documentation standards.

The template

SSubjective

Chief complaint
In the patient's words, with duration.
History of present illness
Onset, location, duration, character, aggravating/relieving factors, radiation, timing, severity. Associated symptoms and pertinent negatives.
Review of systems
Systems relevant to the complaint.
Past medical / surgical history
 
Medications
Name, dose, route, frequency.
Allergies
Drug and reaction.
Family history
 
Social history
Tobacco, alcohol, drugs, occupation, living situation.

OObjective

Vital signs
BP, HR, RR, temperature, SpO2 with oxygen source.
General
Appearance, distress.
Exam
By system, focused on the complaint.
Data
Labs, imaging, ECG, results reviewed.

AAssessment

Summary
Age, sex, relevant history, presenting problem.
Leading diagnosis
With the findings that support it.
Differential
What else, and why less likely. Include must-not-miss diagnoses.

PPlan

Diagnostics
Tests to order.
Treatment
Medications (drug, dose, route, frequency, duration) and other therapy.
Education
What you discussed.
Referrals
 
Follow-up
When, and with whom.
Return precautions
Specific warning signs.

Where does each piece go?

Ask one question about each piece of information. The answer tells you the section.

S: Did the patient tell me?Symptoms, history, medications, allergies, family and social history, review of systems, and what family, EMS or old records report. Name the source when it isn't the patient.
O: Did I see, measure, or test it?Vital signs, exam findings, observed behavior and mental status, scores you measure, labs, imaging, ECGs, and results you reviewed.
A: What do I think it means?Your diagnosis or differential, the evidence for it, how sick the patient is, the status of chronic problems, and what you must not miss.
P: What are we doing about it?Tests, treatment, procedures done, education, referrals, disposition, follow-up with a timeframe, and return precautions.

Easy to mix up

Pain score ("8 out of 10") → Subjective
The patient rates it. You didn't measure it, even when it's charted next to the vitals.
Labs you're ordering → Plan
Their results go in Objective once you have them.
Lab and imaging results → Objective
Data. What they mean goes in Assessment.
ECG findings ("ST elevation in II, III, aVF") → Objective
The tracing is data. "Inferior STEMI" is your Assessment.
History from family, EMS, or old records → Subjective
Still history. Name the source: "per wife," "per EMS."
Mood in the patient's words → Subjective
"I feel hopeless." Quote it.
Affect and thought process → Objective
You observe these. They're part of the mental status exam.
Fetal movement she feels → Subjective
Fetal heart tones and fundal height, which you measure, are Objective.
Scores and measurements you take (GCS, peak flow) → Objective
Risk scores that interpret the picture (HEART) fit in Assessment.
Applying a decision rule (Ottawa ankle rules) → Assessment
The findings are Objective; concluding "fracture unlikely" is reasoning.
Vaccines given today → Plan
Vaccine history the patient reports is Subjective.
Diagnoses on the problem list from before → Subjective
Past medical history. Today's diagnosis and its status are Assessment.

Specialty SOAP templates

Specialties document differently. Each template shows what that specialty emphasizes and what students most often leave out.

Internal MedicineComplex adults with several problems at once. The note is organized around a problem list.Download PDFFamily MedicineContinuity care: today's concern plus chronic disease and prevention, in the context of the whole person.Download PDFEmergency MedicineRule out what's dangerous, treat what's urgent, and decide where the patient goes next.Download PDFPediatricsA growing patient with a caregiver as historian. Everything is compared with age-based norms.Download PDFOB/GYN (prenatal)Two patients at once: the pregnant patient and the pregnancy. Gestational age frames everything.Download PDFPsychiatryThe history is the patient's story; the exam is the mental status exam; safety comes first.Download PDFNeurologyWhere in the nervous system is the problem, and when did it start?Download PDFCardiologyCharacterize the symptom, weigh cardiac risk, and connect ECG and labs to the story.Download PDFPulmonologyHow hard is the patient working to breathe, and why?Download PDFOrthopedicsHow it happened, what's injured, and whether the limb is safe.Download PDFDermatologyDescribe it so precisely that someone who hasn't seen it could picture it.Download PDFGeriatricsFunction and goals matter as much as diagnoses. Look for the geriatric syndromes.Download PDFSurgery (post-op)A daily progress note: is recovery on track, and is anything going wrong?Download PDF

Practice with real cases

SOAPy gives you realistic patient cases. Write the note, then see exactly what you missed, section by section. It also has a daily quiz on where everything goes. Free to start.