As the human healthcare system advances, one essential aspect remains unchanged — the need for accurate patient documentation.

One effective method to achieve this goal is through the SOAP approach. SOAP notes streamline the recording of patient information, progress monitoring, and maintenance of precise medical records in a structured format.

Yet, crafting these notes from the ground up can seem overwhelming. This is where SOAP note templates prove invaluable.

In this blog post, we'll explore 10 SOAP note examples designed to streamline your patient documentation workflow. These readily available templates cater to different specialties and adhere to current industry standards.

10 SOAP Note Examples

1. Pediatrics SOAP Note Example

Subjective:

‍The patient is a 5-year-old male presenting with a chief complaint of fever and cough for the past three days. The parent reports no significant improvement with over-the-counter medications.

Objective:

• Vital Signs:
  • Temperature: 101°F
  • Heart rate: 110 bpm
  • Respiratory rate: 24 bpm
  • Blood pressure: 100/60 mmHg
• Physical Examination:
  • General: Alert and oriented, cooperative.
  • HEENT: Clear nasal discharge, pharynx mildly erythematous, no tonsillar exudates.
  • Lungs: Bilateral scattered crackles on auscultation.
  • Heart: Regular rate and rhythm, no murmurs.
  • Abdomen: Soft, non-tender, no organomegaly.
  • Skin: No rashes or lesions observed.

Assessment:

1. Acute viral upper respiratory infection with fever.
2. Possible viral pneumonia, given the crackles on lung auscultation.

Plan:

1. Symptomatic management:
   • Acetaminophen for fever.
   • Encourage fluids and rest.
   • Nasal saline drops for congestion.
2. Follow-up in 3 days for reassessment.
3. Educate parents on signs of respiratory distress and when to seek immediate medical attention.

2. Dermatology SOAP Note Example

Subjective:

‍The patient is a 30-year-old female presenting with a chief complaint of a rash on her arms and legs for the past week. She reports itching and discomfort, especially at night.

Objective:

• Vital Signs: Within normal limits.
• Skin Examination:
  • Arms: Multiple erythematous papules and vesicles scattered bilaterally, consistent with allergic contact dermatitis.
  • Legs: Similar lesions noted, more pronounced on the lower legs.
  • No signs of infection or systemic involvement observed.

Assessment:

1. Allergic contact dermatitis secondary to exposure to a new laundry detergent or fabric softener.
2. Rule out other potential triggers such as new skincare products or environmental allergens.

Plan:

1. Topical corticosteroid cream (1% hydrocortisone) for affected areas twice daily for 2 weeks.
2. Advised patient to avoid the suspected allergen and switch to hypoallergenic laundry products.
3. Educated patient on proper skincare practices and the importance of moisturizing regularly.
4. Follow-up in 2 weeks for reevaluation and adjustment of treatment if necessary.

3. Oncology SOAP Note Example

Subjective:

‍The patient is a 60-year-old male with a history of stage III colon cancer, currently undergoing chemotherapy with FOLFOX regimen. He presents today for his scheduled follow-up appointment.

Objective:

• Vital Signs: Stable, within normal limits.
• Physical Examination:
  • Abdomen: No palpable masses or tenderness.
  • Skin: No new lesions or changes noted.
  • Neurologic: Alert and oriented, no focal deficits.
  • Lymph Nodes: No palpable lymphadenopathy.
• Laboratory Results:
  • CBC: Hemoglobin 12.5 g/dL, WBC 6.8 x 10^9/L, Platelets 180 x 10^9/L.
  • Liver Function Tests: Within normal limits.
  • CEA (Carcinoembryonic Antigen): Trending down from previous levels.

Assessment:

1. Ongoing management of stage III colon cancer with FOLFOX chemotherapy.
2. Clinical response to treatment with stable disease and improving tumor markers.
3. No new concerning symptoms or complications reported.

Plan:

1. Continue with scheduled FOLFOX chemotherapy cycles as per protocol.
2. Schedule CT scan of the abdomen and pelvis in 3 months for response assessment.
3. Educate patient on potential side effects and management strategies.
4. Encourage regular follow-up appointments for monitoring and supportive care.

4. Neurology SOAP Note Example

Subjective:

‍The patient is a 45-year-old female presenting with a chief complaint of persistent headaches and intermittent dizziness for the past month. She describes the headaches as throbbing in nature, located primarily in the frontal region, and exacerbated by stress.

Objective:

• Vital Signs: Within normal limits.
• Neurological Examination:
  • Cranial Nerves: Intact bilaterally.
  • Motor: Normal strength in all extremities.
  • Sensory: No deficits noted.
  • Reflexes: Physiological reflexes present and symmetric.
  • Coordination: Normal finger-to-nose and heel-to-shin tests.
  • Gait: Normal, no abnormalities observed.

Assessment:

1. Primary headache disorder, likely migraine without aura based on the patient's description.
2. Rule out secondary causes of headache such as intracranial pathology or medication overuse.

Plan:

1. Start migraine prophylaxis with a trial of amitriptyline 25 mg nightly.
2. Recommend lifestyle modifications including stress management techniques and regular exercise.
3. Order brain MRI to rule out structural abnormalities if symptoms persist or worsen.
4. Educate patient on migraine triggers and provide a headache diary for tracking symptoms.
5. Follow-up in 4 weeks for treatment response assessment and further management.

5. Pathology SOAP Note Example

Subjective:

‍The patient is a 55-year-old male with a history of chronic hepatitis B infection, presenting for liver biopsy due to elevated liver enzymes and suspicion of fibrosis progression.

Objective:

• Biopsy Findings:
  • Specimen: Liver tissue obtained via percutaneous needle biopsy.
  • Gross Examination: Liver tissue measuring 2.5 cm in length, tan-yellow in color.
  • Microscopic Examination:
    • Hepatocytes: Mild ballooning degeneration with scattered inflammation.
    • Fibrosis: Stage 2 fibrosis with portal fibrosis and rare bridging fibrosis.
    • No evidence of cirrhosis or hepatocellular carcinoma identified.

Assessment:

1. Chronic hepatitis B infection with evidence of fibrosis progression (stage 2).
2. No significant necroinflammatory activity or cirrhosis noted on biopsy.

Plan:

1. Provide pathology report to the referring physician for further management.
2. Consider antiviral therapy for chronic hepatitis B to prevent disease progression.
3. Schedule follow-up biopsy in 12 months to monitor fibrosis progression and treatment response.

6. Rheumatology SOAP Note Example

Subjective:

‍The patient is a 65-year-old female presenting with a chief complaint of joint pain and stiffness, primarily affecting her hands and knees for the past six months. She reports morning stiffness lasting more than 30 minutes and difficulty with activities of daily living.

Objective:

• Vital Signs: Within normal limits.
• Musculoskeletal Examination:
  • Hands: Bilateral swelling and tenderness of proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints.
  • Knees: Mild effusion with limited range of motion and tenderness on palpation.
  • No skin changes, rash, or other joint involvement noted.

Assessment:

1. Suspected rheumatoid arthritis (RA) based on clinical presentation and joint examination findings.
2. Rule out other inflammatory arthropathies such as psoriatic arthritis or systemic lupus erythematosus.

Plan:

1. Order laboratory tests including rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, complete blood count (CBC), and erythrocyte sedimentation rate (ESR) to confirm diagnosis and assess disease activity.
2. Initiate treatment with a disease-modifying antirheumatic drug (DMARD) such as methotrexate.
3. Refer to physical therapy for joint mobility exercises and functional assessments.
4. Educate patient on RA management, including the importance of medication adherence and regular follow-up visits.
5. Schedule follow-up in 4 weeks for treatment response evaluation and adjustment if needed.

7. Psychiatry SOAP Note Example

Subjective:

‍The patient is a 30-year-old female presenting with a chief complaint of persistent low mood, decreased energy, and difficulty concentrating for the past six months. She reports feelings of hopelessness and occasional thoughts of self-harm

Past Psychiatric History:

• Diagnosed with generalized anxiety disorder (GAD) in her late 20s, managed with cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).
• History of alcohol use disorder in her 30s, currently abstinent following a successful outpatient rehabilitation program three years ago.
• No history of psychotic disorders, bipolar disorder, or significant mood disturbances.

Objective:

• Appearance and Behavior:
  • Patient appears sad and withdrawn, maintaining minimal eye contact during the interview.
  • Speech is slow and monotone, with pauses between sentences.
• Mood/Affect:
  • Depressed mood observed, affect constricted.
• Thought Process:
  • No evidence of hallucinations or delusions.
  • Patient expresses negative automatic thoughts and self-critical beliefs.
• Cognitive Function:
  • Mild impairment in attention and concentration noted.
• Insight/Judgment:
  • Limited insight into the impact of her symptoms on daily functioning.
  • Judgment appears intact regarding safety and self-care.

Assessment:

1. Major depressive disorder, moderate severity, with suicidal ideation.
2. Generalized anxiety disorder (GAD) with panic attacks, recurrent, and persistent.
3. Past history of alcohol use disorder, currently in remission.
4. Consider comorbid social anxiety disorder given panic attack triggers.

Plan:

1. Continue cognitive-behavioral therapy (CBT) for anxiety management and coping skills.
2. Ensure patient safety by implementing a safety plan and discussing coping strategies for managing suicidal thoughts.
3. Initiate pharmacotherapy with an SSRI (e.g., sertraline) for long-term symptom control..
4. Refer patient to psychotherapy for cognitive-behavioral therapy (CBT) or supportive counseling.
5. Monitor for medication side effects and treatment response closely.
6. Educate patient and family members on depression, treatment options, and the importance of adherence to treatment.
7. Schedule follow-up in 2 weeks for symptom review and adjustment of treatment as needed.

8. Physical Therapy SOAP Note Example

Subjective:

‍The patient is a 50-year-old male presenting with a chief complaint of lower back pain (LBP) following a lifting injury at work two weeks ago. He describes the pain as dull and achy, localized to the lumbar spine region, exacerbated by bending forward and prolonged sitting.

Objective:

• Observation:
  • Patient exhibits antalgic gait with reduced stride length and guarding of the lower back.
  • Limited lumbar range of motion in all planes, especially flexion and rotation.
• Palpation:
  • Tenderness noted over the lumbar paraspinal muscles and sacroiliac joints.
• Strength Testing:
  • Lower extremity strength within normal limits.
  • Decreased lumbar extensor strength due to pain inhibition.
• Range of Motion (ROM):
  • Lumbar flexion: 20 degrees (normal 40-60 degrees).
  • Lumbar extension: 10 degrees (normal 20-30 degrees).
• Special Tests:
  • Positive straight leg raise test indicating possible nerve root irritation.

Assessment:

1. Acute mechanical low back pain (LBP) with possible lumbar radiculopathy.
2. Impaired lumbar spine mobility and muscle strength due to pain and guarding.
3. Risk factors include repetitive lifting and poor ergonomics at work.

Plan:

1. Pain management:
   • Modalities: Heat therapy to alleviate muscle spasm and promote relaxation.
   • Manual therapy techniques: Soft tissue mobilization and gentle joint mobilization to improve lumbar mobility.
   • Education on proper body mechanics and ergonomic principles to prevent re-injury.
2. Exercise program:
   • Core stabilization exercises to improve lumbar spine stability and support.
   • Flexibility exercises for the hip flexors and hamstrings to alleviate stress on the lumbar spine.
3. Activity modification:
   • Advise temporary restriction on heavy lifting and prolonged sitting.
4. Home exercise program:
   • Provide printed instructions and demonstration of exercises for home practice.
5. Follow-up in 1 week for reassessment of symptoms, progress, and adjustment of treatment plan as needed.

9. Occupational Therapy SOAP Note Example

Subjective:

‍The client is a 60-year-old male presenting with a chief complaint of difficulty performing activities of daily living (ADLs) independently following a stroke six months ago. He reports decreased strength and coordination in the right upper extremity (RUE), impacting his ability to dress, groom, and complete household tasks.

Objective:

• Observation:
  • Client demonstrates decreased range of motion (ROM) and grip strength in the RUE.
  • Functional Assessment:
    • Dressing: Requires assistance with fastening buttons and zippers due to limited dexterity.
    • Grooming: Difficulty using toothbrush and comb with RUE.
    • Household tasks: Unable to lift objects with RUE or perform tasks requiring bilateral coordination.
• Motor Function:
  • RUE strength: 3/5 on Manual Muscle Testing (MMT) for shoulder abduction, elbow flexion, and wrist extension.
  • Decreased fine motor coordination and precision in RUE.
• Cognitive Function:
  • Intact orientation, attention, and memory.
  • Impaired executive function affecting task planning and organization.

Assessment:

1. Right-sided hemiparesis secondary to stroke, resulting in functional deficits in ADLs.
2. Decreased strength, coordination, and fine motor control in the RUE impacting independence.

Plan:

1. Occupational therapy intervention:
   • Therapeutic Exercises: Focus on improving RUE strength, ROM, and coordination using progressive resistive exercises and functional activities.
   • Neuromuscular Reeducation: Facilitate motor control and retraining of fine motor skills through repetitive tasks and sensory-motor activities.
   • Adaptive Equipment: Recommend use of adaptive devices such as buttonhooks, reachers, and modified grooming aids to enhance independence.
2. Activity Modification:
   • Teach compensatory strategies for ADLs, including task simplification and use of alternate techniques.
3. Home Modifications:
   • Recommend environmental modifications for safety and accessibility, such as grab bars in the bathroom and raised toilet seats.
4. Caregiver Education:
   • Provide education and training to family members on assisting with transfers and supporting independence in ADLs.
5. Progress Monitoring:
   • Conduct regular reassessments of functional status and goal attainment to modify treatment plan as needed.
6. Follow-up:
   • Schedule weekly therapy sessions to monitor progress and provide ongoing support and guidance.

10. Nursing SOAP Note Example

Subjective:

‍The patient is a 65-year-old male admitted with a diagnosis of pneumonia. He reports cough with purulent sputum, shortness of breath, and fever for the past three days. The patient also complains of generalized weakness and decreased appetite.

Objective:

• Vital Signs:
  • Temperature: 101.5°F
  • Heart rate: 98 bpm
  • Respiratory rate: 24 bpm
  • Blood pressure: 130/80 mmHg
• Respiratory Assessment:
  • Auscultation reveals coarse crackles in bilateral lower lung fields.
  • Productive cough with greenish-yellow sputum noted.
• Physical Examination:
  • Decreased breath sounds in lower lobes.
  • Diminished chest expansion.
• Laboratory Results:
  • CBC: Elevated white blood cell count (WBC) indicating infection.
  • Chest X-ray: Consolidation in the right lower lobe consistent with pneumonia.
• Fluid Intake and Output:
  • Intake: 1200 mL (oral and IV fluids)
  • Output: 800 mL (urine output)

Assessment:

1. Pneumonia, likely bacterial in nature, based on clinical presentation and diagnostic findings.
2. Respiratory distress with productive cough, fever, and crackles on auscultation.
3. Decreased fluid intake and output suggestive of mild dehydration.

Plan:

1. Respiratory Support:
   • Administer oxygen therapy via nasal cannula at 2 liters per minute to maintain oxygen saturation above 92%.
   • Encourage deep breathing exercises and incentive spirometry to improve lung expansion.
2. Medication Administration:
   • Initiate antibiotic therapy with ceftriaxone and azithromycin as per hospital protocol.
   • Administer antipyretics (acetaminophen) for fever management.
3. Fluid Management:
   • Encourage increased fluid intake orally to maintain hydration status.
   • Monitor fluid balance closely and assess for signs of dehydration.
4. Nutrition Support:
   • Offer small, frequent meals with high-calorie, high-protein options to improve nutritional intake.
5. Patient Education:
   • Educate patient on the importance of completing antibiotic course, respiratory hygiene, and signs of worsening symptoms.
6. Collaborate with Interdisciplinary Team:
   • Communicate findings and updates to the healthcare team including physicians, respiratory therapists, and nutritionists.
7. Monitor:
   • Monitor vital signs, oxygen saturation, respiratory status, fluid balance, and response to treatment regularly.
8. Follow-up:
   • Schedule follow-up assessments to evaluate treatment response, assess for complications, and plan discharge.

‍