SOAP Notes Example for Your Inspiration

The day in the life of a healthcare provider is nothing short of busy, stressful, and at times chaotic. In these conditions, concise and precise patient information is priceless. SOAP notes are a standardized, effective way to communicate it.

SOAP notes have several advantages. As a framework, they provide a uniform structure for patient notes, meaning any clinician can quickly locate relevant information. It’s also meant to be concise and include only the most useful data, speeding up communication.

Writing concise yet comprehensive SOAP notes is a skill. Our nursing essay writers decided to help you build it with this guide, complete with seven examples. Keep reading to find the SOAP note example medical student in your field will find useful!

What Is a SOAP Note, Exactly?

A SOAP note is a standardized framework for writing clinical notes. SOAP itself is an acronym and stands for the four components of the note:

• Subjective: Personal views, feelings, and experiences of the patient, including reported symptoms; i.e., what the patient tells you
• Objective: Collected patient data, such as test results or vital signs
• Assessment: A synthesis of subjective and objective evidence, with differential diagnosis if applicable
• Plan: Description of the required future tests, treatment, or consultation

While you’re supposed to list components in the order above, they might be shuffled around. In that case, you’d be asked to write an APSO note: Assessment, Plan, Subjective, Objective.

SOAP notes are ubiquitous in clinical documentation, with nurses, doctors, and therapists alike writing and perusing them on a daily basis. The reason is simple: a standardized approach to patient notes makes relevant information easy to locate and quick to grasp.

SOAP notes also ensure your writing is clear and precise, thus mitigating the risk of some information being left forgotten and undocumented. At the same time, this approach also states that only the most relevant, essential information should be jotted down.

7 SOAP Notes Examples

The key to writing good SOAP notes is communicating only the most relevant information in as few sentences as possible. Check out our seven examples to see what it means in practice.

Nursing SOAP Note Example

Imagine you’re tending to a 62-year-old patient who had his hip replacement surgery two days ago. He reports moderate hip pain during movement. Here’s your SOAP note for this patient:

S: Patient is a 62-year-old male, 2 days post right hip replacement. Reports hip pain rated 6/10 during movement, described as aching and localized. Denies numbness, tingling, chest pain, or shortness of breath. Expresses concern about mobility progress.

O: Vital signs stable: BP 126/78, HR 78, RR 16, Temp 37°C. Surgical dressing intact with mild serosanguinous drainage. Ambulating short distances with a walker, requiring standby assist. No signs of infection or excessive swelling.

A: Post-operative status, day 2, right hip arthroplasty. Pain moderately controlled but impacting mobility. Surgical site stable with expected drainage. Functional mobility improving, but still requires assistance. No acute complications identified at present.

P: Continue pain management with prescribed analgesics before mobilization. Monitor the surgical site for infection or increased drainage. Encourage gradual ambulation with a walker under supervision. Reassess pain and mobility tomorrow. Educate the patient on safe transfer techniques.

Physical Therapy SOAP Note Example

Let’s say you tend to a 64-year-old woman who recently had her knee replaced and is now in recovery. Here’s an example of a SOAP note you can create to guide her rehab:

S: 64-year-old female, 3 weeks post total knee arthroplasty. Reports stiffness, especially in the mornings. Pain 4/10 during bending. Denies redness, swelling, or fever. Eager to regain mobility for the daily walking routine.

O: Right knee flexion: 90°, extension: -5°. Gait with walker, minimal limp. Surgical incision healing well. Mild swelling present, no erythema. Vitals stable. Quadriceps strength: 4-/5.

A: Post-operative knee stiffness and mild swelling, consistent with the recovery stage. Gradual improvements in ROM and strength. Functional mobility is improving, but not yet full.

P: Continue ROM and strengthening exercises. Add gentle stretching in the mornings. Apply ice after sessions. Progress ambulation distance. Reassess ROM and strength in one week.

Mental Health SOAP Note Example

An Iraq War veteran reaches out to you and schedules an appointment. Here’s an example of a SOAP note you might jot down after your first session:

S: 37-year-old veteran reports recurrent nightmares, hypervigilance, irritability, and avoidance of crowded places. Describes startle response when hearing loud noises. Sleep is disrupted 4-5 nights weekly. Denies suicidal ideation. Expresses frustration about limited social engagement.

O: Alert, oriented. Speech clear, mood anxious, affect restricted. Hypervigilant behavior is noted in the waiting area. No psychosis. GAD-7 score: 16. PCL-5 score: elevated.

A: Post-traumatic stress disorder, persistent symptoms affecting sleep, mood, and daily functioning. No acute safety concerns. Avoidant behaviors reinforce social withdrawal. Symptoms consistent with chronic PTSD.

P: Continue trauma-focused psychotherapy. Discuss potential SSRI initiation with a psychiatrist. Encourage grounding techniques. Recommend gradual exposure to safe social settings. Follow up in 1 week to assess symptom changes.

Pediatric SOAP Note Example

As a pediatric doctor, you might deal with asthma patients relatively often. Here’s a SOAP note you might write after examining an eight-year-old presenting symptoms of asthma:

S: 8-year-old male with a history of asthma presents with increased wheezing and nighttime cough twice weekly. Uses an albuterol inhaler as needed. Denies fever or chest pain. Mother reports symptoms triggered by seasonal pollen.

O: RR 20, SpO₂ 96% on room air. Mild expiratory wheezes bilaterally. No retractions. Peak flow: 85% predicted. No cyanosis. Vitals otherwise stable.

A: Mild intermittent asthma with seasonal trigger, currently experiencing mild exacerbation. No respiratory distress. Good response to rescue inhaler noted.

P: Continue albuterol as needed. Start daily antihistamine during pollen season. Review inhaler technique. Schedule follow-up in 2 weeks. Provide an asthma action plan for school.

Occupational Therapy SOAP Note Example

Imagine you’ve just examined a patient who needs occupational therapy after a surgery on his right hand, which is his dominant one. Your SOAP note after the appointment might look like this:

S: 40-year-old male, 3 weeks post-tendon repair in the dominant right hand. Reports stiffness, limited grip strength, and difficulty performing fine motor tasks. Denies numbness, swelling, or severe pain. Wants to return to work soon.

O: Surgical incision healed, no signs of infection. Grip strength 12 kg (left hand 36 kg). Limited finger flexion. Mild stiffness with wrist extension. Sensation intact to light touch.

A: Reduced grip strength and ROM following tendon repair, impacting fine motor skills and work readiness. Progressing well post-operatively without complications.

P: Initiate grip-strengthening and fine motor coordination exercises. Recommend a home exercise program twice daily. Gradually increase resistance. Reassess function and strength in one week.

General Practice SOAP Note Example

General practice might not be as stress-inducing and chaotic as working in the ER, but your notes still need to be pristine. Here’s an example of one for a patient who came to you for a routine physical exam:

S: 29-year-old male presents for annual exam. No medical complaints. Exercises regularly, balanced diet. No significant past history. Denies tobacco use; drinks alcohol socially. No family history of chronic disease reported.

O: Vitals: BP 118/72, HR 72, RR 16, Temp 36.7°C. BMI 23. Normal heart, lung, and abdominal exams. Skin clear. No musculoskeletal or neurological deficits.

A: Healthy adult male with normal examination findings. No immediate medical concerns identified. Preventive screening and lifestyle counseling are appropriate.

P: Order routine labs (CBC, CMP, lipid panel). Continue regular exercise and a healthy diet. Provide vaccine updates as needed. Schedule the next annual exam in one year.

Emergency Room SOAP Note Example

Like it or not, you can’t avoid victims of vehicle collisions if you work in the ER. Here’s an example of a SOAP note you might write for a patient delivered to the ER after a motor vehicle collision (MVC):

S: 45-year-old female, restrained driver in low-speed MVC. Reports neck pain and mild headache. No loss of consciousness, dizziness, or nausea. Denies numbness or weakness in extremities.

O: BP 128/80, HR 84, RR 16, Temp 36.8°C. Tenderness over the midline cervical spine. No visible bruising or swelling. Neuro exam normal. Full extremity strength.

A: Neck pain post-MVC, likely cervical strain versus whiplash. No neurological deficits or red flags noted.

P: Apply cervical collar until imaging rules out fracture. Provide analgesics. Order cervical spine X-ray. Monitor for neurological changes. Reassess after imaging results.

How to Ace Your Next SOAP Note: Expert Tips

Taking your SOAP notes from okay to good and then great will take you some time. Here’s some of the wisdom our nursing experts would like to impart on you to help you speed up your progress:

• Don’t take too much time to write the SOAP note; 5-7 minutes should be enough
• Keep your notes concise; strive to use as few words as possible
• Avoid biased, judgmental, or vague statements in your notes
• Re-read your note and ask yourself: Is it clear enough for someone who isn’t familiar with the patient?
• Be specific, accurate, and factual in both the Subjective and Objective sections
• Don’t confuse Subjective with Objective information: relay the patient’s own words in the former and focus on observations and clinical data in the latter
• Strive to be comprehensive in your notes instead of making them long
• Separate essential information from the rest and focus on including only that information

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In Closing

SOAP notes are the cornerstone of clinical documentation: they provide a universal framework for recording relevant information and communicating it to other professionals. The SOAP notes might also come in handy for insurance purposes or legal disputes.

At the end of the day, SOAP notes are an effective documentation and communication tool for recording the most relevant information as efficiently as possible.

Once you get the hang of it, you’ll also be able to separate essential data from unnecessary details and jot it down in no time at all. So, take your time to practice. And, of course, don’t hesitate to use our examples of SOAP notes as templates for your own notes!

Preparing to submit a medical school application soon? Check out our 15 compelling medical school personal statement examples to get inspired!

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