Writing clinical notes shouldn’t feel harder than treating the patient. Yet for many doctors, SOAP notes turn into rushed, messy entries that are hard to read, review, or bill from later. A well-written SOAP note does more than record a visit. It protects care quality, supports clear thinking, and helps the whole team stay on the same page. When done right, it also saves time and reduces errors.
In this blog, you’ll see six practical SOAP note examples based on real-world visits. Each example shows how to turn patient details into clean, useful documentation you can trust and reuse.
SOAP Note Template Doctors Can Reuse
You don’t have time to build documentation from scratch every encounter. This soap note example gives you speed without sacrificing the details that protect you, a balance platforms such as Freed and Freed AI are designed to support.
SOAP note template structure (SOAP) with minimum required elements
Subjective: Chief complaint, history of present illness with timeline, pertinent review of systems, relevant past medical and surgical history, current medications and known allergies, patient’s own goals or concerns.
Objective: Vital signs, targeted physical exam findings, pertinent lab or imaging data, anything you directly observed.
Assessment: Primary and differential diagnoses, severity classification, your clinical reasoning, active problem list with status updates.
Plan: Diagnostic workup, therapeutic interventions, medications with specific dosing and frequency, patient education points, follow-up timing, return precautions, referrals if needed, documentation of shared decision-making.
Documentation quality checklist (fast “do I have enough?” scan)
Problem-focused language, timestamps, quantifiable findings, risk stratification, clear follow-up triggers, medication reconciliation, explicit patient instructions.
Specialty add-ons that strengthen SOAP note medical documentation
ER notes gain strength from decision rules. Primary care charts need chronic disease metrics. Orthopedics demand neurovascular checks. Psychiatry requires mental status exams. Dermatology thrives on lesion morphology. Pediatrics needs growth percentiles and weight-based dosing.
Now let’s see how this template performs when you’re managing a chronic condition that hits 70% of primary care desks every single week.
SOAP Note Example 1: Primary Care: Hypertension Follow-up
Chronic disease management demands documentation of adherence patterns, home monitoring trends, and lifestyle obstacles, all necessary to justify treatment adjustments and prove medical necessity.
Real-world use case
Blood pressure is still above target despite current regimen; patient admits inconsistent medication use; home readings bounce around; barriers to diet and exercise complicate optimization.
SOAP note for doctors (fully written)
S: Patient taking lisinopril 20 mg daily “most of the time,” admits missing weekend doses. Home BP log: 135–150/85–95 mmHg over two weeks. No chest pain, dyspnea, or headache. Fast food is frequent due to a demanding work schedule. Exercise minimal.
O: BP 148/92 mmHg (repeat 145/90 mmHg), HR 76, BMI 32. Cardiovascular: regular rhythm, no murmurs. Lungs: clear bilaterally. BMP: Na 138, K 4.2, Cr 1.0. Lipids: LDL 125 mg/dL.
A: Uncontrolled essential hypertension on monotherapy, nonadherence likely contributing. Obesity. Stable hyperlipidemia.
P: Increase lisinopril to 40 mg daily. Recheck BMP and BP in four weeks. Counseled on adherence and proper home monitoring technique. Encouraged 30 minutes walking daily. Return precautions for chest pain or severe headache.
“Outrank” value: clinician reasoning + measurable targets
State your BP goal explicitly, define titration thresholds, outline monitoring intervals, and use language that establishes medical necessity for every intervention.
While primary care emphasizes longitudinal tracking, emergency medicine demands rapid-fire risk stratification, and your documentation becomes your strongest legal shield when things go sideways.
SOAP Note Example 2: Emergency/Urgent Care: Acute Chest Pain Rule-Out
Chest pain visits require clear differential thinking and transparent decision logic to defend your disposition choice and minimize liability exposure.
Real-world use case
The patient arrives with chest discomfort; you’re weighing ACS, GERD, musculoskeletal causes; your chart must justify the workup and the decision to discharge or admit.
soap note example
S: Sudden chest tightness started two hours ago, non-radiating, no dyspnea or diaphoresis. Denies nausea. No cardiac history. Risk factors: HTN, active smoker.
O: BP 138/84, HR 88, RR 16, SpO₂ 98% RA. Cardiac exam: unremarkable. ECG: NSR, no ST abnormalities. Troponin at 0 and 3 hours: negative. CXR: clear lung fields.
A: Chest pain, low ACS probability per HEART score 3. Favoring musculoskeletal or GERD etiology.
P: Discharge with PPI trial. Strict return precautions: worsening pain, SOB, diaphoresis. PCP follow-up one week.
Documentation tips that reduce liability and denials
Name your differential, cite the scoring tool, document shared decision-making, and tie discharge instructions directly to risk factors.
Emergency charts lean on validated scoring tools; orthopedic documentation lives or dies on exam precision that justifies imaging orders, specialist referrals, and conservative versus surgical plans.
SOAP Note Example 3: Orthopedics/Sports Medicine: Acute Knee Injury
Twisting mechanisms, instability complaints, and functional limitations demand detailed physical findings to support imaging decisions and justify treatment pathways.
Real-world use case
A patient twisted knee playing basketball, felt a pop, immediate swelling developed; you’re deciding whether to order an MRI and start conservative management.
soap note example
S: Twisting injury during basketball yesterday, audible pop, immediate swelling onset, unable to bear full weight today. No prior knee surgeries.
O: Moderate effusion present, ROM 10°–90° limited by pain. Positive Lachman test. Neurovascular exam intact distally. X-ray: no fracture identified.
A: Suspected ACL tear with possible meniscal involvement. Acute pain and swelling limiting function.
P: RICE protocol, NSAIDs for pain, knee immobilizer issued, crutches provided. MRI scheduled. Orthopedic follow-up one week. Activity restrictions given, work excuse provided.
Physical exam anchors orthopedic notes, but psychiatry shifts weight to Mental Status Exam findings and safety documentation, equally critical, equally structured, equally defensible.
SOAP Note Example 4: Psychiatry: Major Depressive Disorder Follow-up
Medication management encounters require symptom quantification, explicit safety checks, and coordination with therapy providers.
soap note example
S: Ongoing low mood, disrupted sleep, decreased appetite. PHQ-9 today: 14 (moderate severity). Denies SI/HI. Reports good medication adherence.
O: MSE: appropriate dress/grooming, cooperative, depressed mood, congruent affect, linear thought process, no SI/HI, cognition intact.
A: MDD, partial response to current sertraline dose. Insomnia complicates clinical picture.
P: Increase sertraline to 100 mg daily. Continue weekly individual therapy. Safety plan reviewed with patient. Return two weeks. Crisis resources reviewed.
Psychiatry centers on cognition and risk assessment; dermatology pivots to visible, countable morphology that drives treatment escalation and antibiotic stewardship decisions.
SOAP Note Example 5 , Dermatology: Acne Vulgaris
Moderate inflammatory acne unresponsive to OTC regimens; weighing topical combinations versus systemic therapy.
soap note example
S: Facial acne persisting eight months, failed OTC benzoyl peroxide. The patient worried about permanent scarring.
O: Fifteen papules, ten pustules distributed across the forehead and cheeks. Mild post-inflammatory hyperpigmentation noted.
A: Moderate inflammatory acne vulgaris. Moderate scarring risk.
P: Benzoyl peroxide gel 5% plus tretinoin 0.05% nightly. Will consider oral doxycycline if inadequate response at eight weeks. Follow-up three months.
Dermatology notes succeed with lesion counts and stepwise protocols, but pediatric documentation must marry guideline compliance with precise weight-based calculations and parent-friendly instructions that prevent frantic after-hours calls.
SOAP Note Example 6 , Pediatrics: Otitis Media
Fever and ear pain presentation; deciding between antibiotics and watchful waiting; dosing precision matters enormously.
soap note example
S: Fever to 101°F, pulling at ears, URI symptoms for two days. Attends daycare full-time.
O: Bilateral TMs bulging with erythema. Throat mildly erythematous. Weight: 15 kg.
A: Acute bilateral otitis media. Concurrent viral URI.
P: Amoxicillin 400 mg PO BID × 10 days. Ibuprofen as needed for fever. Return if fever continues beyond 48 hours or pain worsens.
You’ve just reviewed six specialty-driven examples, but templates alone won’t save you. You need sharp habits that speed documentation, satisfy auditors, and protect your license when it counts.
Wrapping Up: Turning Examples Into Better Documentation
Take the SOAP note template, borrow from each soap note example, and apply the practices that accelerate your SOAP note medical documentation. Consistent structure cuts variability, strengthens billing defensibility, and shields you medico-legally. Pick one element you’ll refine this week, maybe adding measurable targets in chronic disease notes, or documenting neurovascular status in every orthopedic chart. Better documentation doesn’t demand more time. It demands better habits, practiced until they become automatic.
Common Questions About SOAP Note Examples
What does a real SOAP note look like?
SOAP notes document relevant patient statements and behaviors (Subjective), measurable clinical data (Objective), your synthesis and diagnosis (Assessment), and next steps (Plan).
Can ChatGPT write a SOAP note?
ChatGPT can generate practice SOAP notes for training, but it’s not HIPAA compliant. Never input real patient data. For actual clinical use, you need a HIPAA-ready documentation solution, not ChatGPT.
How detailed should the assessment be?
Your Assessment must justify medical necessity by connecting findings to diagnoses, clarifying severity, and providing transparent clinical reasoning that supports your Plan.
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