A well-structured SOAP note keeps clinical documentation consistent, supports accurate billing, and gives the next provider a clear picture of the patient encounter. Below is a general-purpose SOAP note template you can copy and adapt for your practice.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements.
Copyable SOAP note template
SUBJECTIVE
Chief complaint: [Patient's primary reason for visit in their own words]
History of present illness (HPI):
- Onset:
- Location:
- Duration:
- Character:
- Aggravating/relieving factors:
- Timing:
- Severity (e.g., pain scale 0–10):
- Associated symptoms:
Review of systems (ROS): [Relevant systems reviewed — document pertinent positives and negatives]
Past medical history (PMH): [Active diagnoses, surgical history, hospitalizations]
Medications: [Current medications with doses]
Allergies: [Medication allergies and reactions]
Social history: [Tobacco, alcohol, occupation, living situation as relevant]
Family history: [Relevant family medical history]
OBJECTIVE
Vital signs: BP ___ | HR ___ | Temp ___ | RR ___ | SpO2 ___ | Weight ___
Physical exam:
- General:
- [System-specific findings organized by body system]
Lab/imaging results: [Include date and source if referencing prior results]
ASSESSMENT
1. [Diagnosis or clinical impression #1] — [brief reasoning or status]
2. [Diagnosis or clinical impression #2] — [brief reasoning or status]
Differential diagnoses (if applicable): [List considered alternatives]
PLAN
1. [Diagnosis #1]:
- Diagnostics ordered:
- Medications prescribed/adjusted:
- Referrals:
- Patient education:
- Follow-up:
2. [Diagnosis #2]:
- [Same structure as above]
Disposition: [Discharge home, admit, transfer, etc.]
How each section works
Subjective
This section captures what the patient reports. It starts with the chief complaint — stated in the patient's own words when possible — followed by a detailed history of present illness. The HPI is where you paint the clinical picture: onset, duration, severity, and the factors that make things better or worse.
Include the review of systems, medication list, allergies, and relevant social and family history here. A thorough Subjective section anchors the rest of the note.
Objective
Objective documents what you observe and measure. Vital signs come first, followed by physical exam findings organized by body system. Include relevant lab values, imaging results, and any point-of-care testing performed during the visit.
Stick to findings, not interpretations. "Lungs clear to auscultation bilaterally" belongs here. "Likely viral URI" belongs in Assessment.
Assessment
The Assessment is where clinical reasoning lives. List each diagnosis or clinical impression with a brief note on your reasoning or the condition's current status (e.g., "well-controlled," "worsening despite current regimen"). If the diagnosis is uncertain, include the differential.
Number your diagnoses — this makes the Plan section easier to follow and supports clear communication with other providers.
Plan
The Plan maps directly to the numbered Assessment. For each diagnosis, document what you are doing about it: tests ordered, medications prescribed or adjusted, referrals, patient education, and follow-up timing.
This section is often the most scrutinized during audits and care transitions, so clarity matters. Avoid vague instructions like "follow up as needed" when you can be specific.
When to customize this template
No single template works perfectly for every encounter. Here are common situations where you should adjust:
- New patient vs. follow-up: New patient visits typically need a full history. Follow-ups can focus on interval changes and the problem list.
- Single complaint vs. multiple problems: For straightforward visits, the template can be streamlined. For patients with several active conditions, expand the Assessment and Plan with numbered entries for each.
- Procedures: If you perform a procedure during the visit, add a Procedure section between Objective and Assessment documenting consent, technique, findings, and complications.
- Preventive visits: Annual wellness exams may benefit from a health maintenance checklist section covering screenings, immunizations, and counseling.
Specialty considerations
Different specialties emphasize different parts of the note:
- Family medicine often needs a broader ROS and health maintenance tracking for chronic disease management.
- Psychiatry requires a mental status exam in the Objective section and careful treatment plan documentation.
- Urgent care prioritizes concise notes with clear discharge instructions and return precautions.
- Cardiology focuses on cardiovascular risk factors, medication reconciliation, and imaging interpretation.
Browse our specialty pages for templates tailored to specific fields.
Using AI to speed up SOAP note documentation
Writing SOAP notes by hand or from memory after a full day of patient visits is one of the biggest sources of documentation burden. AI-generated SOAP notes can draft structured notes from patient encounters or dictation, giving clinicians a starting point to review rather than a blank page.
With custom clinical templates, you can configure the output to match your preferred structure — so the AI draft already looks like the notes you would write yourself.
Dictum turns patient encounters and dictation into structured, review-ready SOAP notes. The clinician stays in control: every note is reviewed and signed by the provider before it goes into the chart.
Frequently asked questions
What does SOAP stand for in a medical note? SOAP stands for Subjective, Objective, Assessment, and Plan. It is a widely used format for organizing clinical documentation in a consistent, structured way.
Can I modify this SOAP note template for my specialty? Yes. This template is a starting point. Most clinicians customize the Subjective and Plan sections based on their specialty, patient population, and organizational requirements.
Is the SOAP format required for billing? SOAP is not the only accepted format, but its structured approach supports clear documentation of medical decision-making, which payers and auditors look for during claims review.
Can AI generate SOAP notes automatically? AI tools like Dictum can draft SOAP notes from patient encounters or dictation. The clinician reviews, edits, and signs the final note, keeping clinical judgment at the center of the process.
What is the difference between SOAP and DAP notes? DAP (Data, Assessment, Plan) combines the Subjective and Objective sections into one Data section. SOAP is more common in primary care and general medicine; DAP is often used in behavioral health settings.
Where do I document vitals in a SOAP note? Vitals go in the Objective section along with physical exam findings, lab results, and any measurable clinical data.
How long should a SOAP note be? Length varies by visit complexity. A straightforward follow-up may take a few lines per section, while a new patient evaluation with multiple concerns will be longer. Aim for thorough but concise.
Ready to spend less time on notes? Try Dictum free and see how AI-drafted SOAP notes give you a head start on every chart.