How to write a SOAP note: structure, example, and template

To make a SOAP note, separate the encounter information into four parts: Subjective, Objective, Assessment, and Plan. First, record what the patient reports; then, the observed or measured data; next, your clinical assessment; and finally, the agreed-upon actions and follow-up.

This guide shows how to write each section, includes a complete fictional clinical example, and offers a editable SOAP note template. If you prefer a short version to adapt, see the SOAP note template and example. For a conceptual explanation of the format and professional review, see also what is a SOAP note and what to check before signing it.

The example and template are educational. They must be adapted to the type of care, specialty, organization policies, and applicable requirements. They do not replace clinical judgment.

Practical structure of a SOAP note

Section	What to document	Control question
S - Subjective	Reason for consultation, evolution, symptoms, medical history, treatments, and concerns reported by the patient or caregiver.	Was it clear what the person is referring to and since when?
O - Objective	Vital signs, examination, results, and other data observed, measured, or reviewed during the encounter.	Can each piece of data be identified as observed, measured, or from an available source?
A — Evaluation	Clinical synthesis, problems, diagnostic impression when applicable, level of certainty, and aspects to be confirmed.	Is the assessment supported by the information documented in S and O?
P — Plan	Actions, indications, studies, references, education, follow-up, pending items, and responsible parties when applicable.	Is the next step understood without reconstructing the entire conversation?

How to write a SOAP note step by step

1. Summarize the motive and evolution in Subjective

Start with the reason for the encounter and preserve the chronology that changes the reading of the case. Attribute the source when the information comes from a caregiver, a family member, or a document provided by the patient. Avoid turning the section into a verbatim transcript.

2. Record only available data in Objective

Include exploration findings, measurements, and results reviewed during care. Use units and dates when they provide context. If data was not available, leave it as pending; do not fill in the space with an assumption.

3. Synthesize the reasoning in Evaluation

Connect what was reported and what was observed with your professional assessment. Distinguish an impression, a hypothesis, or a differential diagnosis of a confirmed conclusion. The wording must preserve the actual level of certainty of the meeting.

4. Leave clear actions and pending items in Plan

Document what was agreed upon, what remains to be done, and when it is time to review the case. When a team is involved, identify those responsible and relevant pending tasks. The plan must reflect the professional's decision, not an automatic suggestion.

5. Revise the note as a clinical draft

Before approving or signing, confirm that the note corresponds to the current encounter, that it does not contain unavailable information, and that the assessment and plan reflect the decisions made. A clear structure facilitates review, but does not replace it.

Complete example of a SOAP note

The following case is fictitious and abbreviated. Its objective is to show how to distribute information; it does not propose a course of action for a real patient.

Fictional encounter: outpatient follow-up

S — Subjective. 52-year-old adult attends blood pressure follow-up. Reports having missed two doses of the prescribed treatment during the last week. Presents a home blood pressure log with readings between 138–148/84–92 mmHg. Denies chest pain, dyspnea, visual disturbances, or new neurological symptoms. Reports no recent changes in other medications.

O — Objective. Office blood pressure: 146/90 mmHg; second measurement: 144/88 mmHg. Heart rate: 76 bpm. The home log provided is reviewed. No signs of acute distress are observed during the encounter.

A — Evaluation. Hypertension under follow-up, with elevated readings in available measurements and reported irregular adherence. No warning symptoms reported during this encounter. Assessment and any treatment changes are the responsibility of the attending professional.

P — Plan. The review of adherence and the agreed schedule, the continuity of home logging, and a new assessment within the timeframe defined by the professional are documented. Pending items, individualized instructions, and the explained care pathway for relevant clinical changes are recorded.

Note that the example does not repeat the entire conversation: it separates the referred experience, the available data, the professional interpretation, and the agreed-upon actions.

Checklist before approving a SOAP note

• The reason for the consultation and the chronology correspond to the current encounter.
• What the patient reports is distinguished from what is observed or measured.
• The dates, units, and sources of relevant results are clear.
• The evaluation maintains the level of real certainty and points out the pending aspects.
• The plan identifies actions, monitoring, and responsible parties where applicable.
• No data that was not available was added.
• The responsible professional reviewed, corrected, and approved the draft.

Common errors when writing SOAP notes

• Copy the entire conversation: An extensive transcription is not a substitute for a prioritized note.
• Mix symptoms and signs: What is referred to belongs to Subjective; what is observed or measured, to Objective.
• Presenting a hypothesis as certainty: The evaluation must preserve clinical uncertainty when it exists.
• Leave an ambiguous plan: The following steps, pending items, and responsible parties must be able to be identified.
• Sign without reviewing: Every assisted draft must be cross-checked against actual care.

How to transfer your SOAP format to Itaca

You can use SOAP as a note structure or start from the format you already use. In Itaca, the clinical note templates they allow maintaining a reusable structure, and Clinical note rules they help maintain consistent criteria. The result remains a draft: you decide what to correct, approve, and sign.

If you work with a team, you can also learn the workflow of clinical documentation for clinics. To begin individually, Create a free account on Itaca.

Don't know if your encounter needs a broader history and physical exam or a problem-oriented note? Compare H&P and SOAP, with examples of both formats.

Reference sources

• SOAP Notes, StatPearls, NCBI Bookshelfdescription of the Subjective, Objective, Assessment and Plan structure.
• Documentation Matters Toolkit, Centers for Medicare & Medicaid Servicesgeneral principles regarding complete, accurate, and timely documentation. Specific requirements depend on the institution and jurisdiction.