SOAP Note Documentation: 10 Best Practices With a Full Sample Note

Good SOAP note documentation records what the patient told you, what you found, what you think and what happens next, in that order. Done well, it lets any colleague pick up the chart and act without calling you.

Done poorly, it costs you twice: once in the time spent writing a bloated note, and again when a reviewer, payer or covering clinician can't follow your reasoning.

This guide is for physicians, nurse practitioners (NPs) and physician assistants (PAs) who want notes that are complete, defensible and faster to write. It covers what belongs in each section, 10 best practices, a full sample note and a copy-ready template.

What is SOAP note documentation?

SOAP stands for Subjective, Objective, Assessment and Plan. It is the most widely used structure for progress notes and problem-focused visits in outpatient and inpatient care.

The format works because it mirrors clinical reasoning. You gather the story, check it against the data, reach a conclusion and act on it. A reader can jump straight to the section they need.

SOAP note documentation example: primary care follow-up

This sample uses a fictional patient with no real identifiers.

Patient: "Ms. K.," 54-year-old female, 3-month follow-up for type 2 diabetes and hypertension. In-person visit.

S – Subjective

• CC: "I'm here for my diabetes check. My sugars have been higher in the mornings."
• HPI: Fasting home glucose 150–180 mg/dL over the past 4 weeks, previously 110–130. Reports eating later at night since starting a new work shift. Taking metformin 1,000 mg twice daily; misses the evening dose "maybe twice a week." No polyuria, polydipsia, blurred vision or hypoglycemia symptoms.
• Hypertension: home BP readings "mostly 130s over 80s." Taking lisinopril 20 mg daily. No headaches, chest pain or dizziness.
• ROS: Negative for foot numbness, foot sores and dysuria. Otherwise negative except as in HPI.
• Allergies: No known drug allergies.

O – Objective

• Vitals: BP 138/86 (repeat 134/84), HR 78, temperature 98.4 °F, weight 192 lb (down 2 lb since last visit), BMI 32.
• Exam: Well-appearing, in no distress. Heart regular rate and rhythm, no murmur. Lungs clear. No lower-extremity edema.
• Diabetic foot exam: Skin intact, no calluses or ulcers. Monofilament sensation intact bilaterally. Dorsalis pedis pulses 2+ bilaterally.
• Labs (drawn 1 week ago): A1c 8.1% (previous 7.4%). Creatinine 0.9 mg/dL, eGFR above 60. Urine albumin-to-creatinine ratio 18 mg/g. LDL 96 mg/dL.

A – Assessment

1. Type 2 diabetes, not at goal. A1c up from 7.4% to 8.1%. Likely driven by missed evening metformin doses and later meals after shift change. No symptoms of hyperglycemia or hypoglycemia. Kidney function normal; no microalbuminuria.
2. Hypertension, near goal. Office BP 134/84 on repeat; home readings consistent. Tolerating lisinopril.
3. Obesity, BMI 32. Weight down 2 lb. Motivated to keep working on it.

P – Plan

1. Diabetes: Discussed adherence; patient prefers once-daily dosing. Switch to metformin extended-release 2,000 mg once daily with evening meal. Discussed adding a second agent if A1c not improved at next check; patient agrees with this plan. Continue home glucose checks, fasting and 2 hours after dinner, 3 days a week.
2. Hypertension: Continue lisinopril 20 mg daily. Bring home BP log to next visit.
3. Prevention: Annual diabetic eye exam due; referral placed to ophthalmology. Continue statin per prior plan.
4. Education: Reviewed timing of meals around shift work and hypoglycemia symptoms. Patient verbalized understanding using teach-back.
5. Follow-up: Repeat A1c and return visit in 3 months, sooner if fasting glucose stays above 200 mg/dL or symptoms develop.

Notice what makes this note work. Each problem in the assessment has a status and a reason. Each plan item maps to a problem. The follow-up line tells the patient and any covering clinician exactly when to act sooner.

10 SOAP note documentation best practices

1. Lead with the patient's own words. Quote the chief complaint. It anchors the note and shows the visit was patient-centered.
2. Write the HPI as a story, not a checklist. Onset, duration, severity, what helps, what doesn't and what changed since last time. Pertinent negatives belong here too.
3. Keep subjective and objective separate. "Patient reports fever" is subjective. "Temp 101.2 °F" is objective. Mixing them weakens both.
4. Document only what you examined. A templated 12-system normal exam you didn't perform is a liability, not a time-saver.
5. Make the assessment show your thinking. Name the problem, give its status and add one line of reasoning. A diagnosis alone tells the reader what you concluded, not why.
6. Number problems and match the plan to them. Problem 1 in the assessment should be Plan item 1. It makes the note scannable and audit-friendly.
7. Be specific in the plan. Drug, dose, route, frequency, duration. "Follow up in 3 months" beats "follow up as needed."
8. Record shared decisions and education. Note what you discussed, the options offered and what the patient chose. Teach-back is worth one line.
9. Include return precautions. Spell out the symptoms or thresholds that should bring the patient back sooner.
10. Finish the note the same day. Notes written days later lose detail, and late entries can draw attention in a records review. Follow your organization's policy on timeliness.

Is a SOAP note a legal document?

Yes. A SOAP note is part of the medical record, and the medical record can be used in billing reviews, peer review and legal proceedings. Treat every note as if someone outside your clinic will read it.

A few practical rules follow from that:

• Never alter a signed note. Use an addendum with the date, time and reason.
• Avoid copy-forward without review. Carried-over text that no longer matches the patient creates contradictions in the record.
• Stay objective. Document behavior and quotes, not opinions about the patient's character.
• Use approved abbreviations only. Check your organization's do-not-use list.

For billing, office visit evaluation and management (E/M) levels are selected based on medical decision-making (MDM) or total time on the date of the encounter. A clear assessment and plan is usually where MDM shows up. Documentation supports billing; it doesn't guarantee it.

SOAP vs. other note formats

APSO is simply SOAP reordered. If your EHR supports it, it can save colleagues time because the assessment and plan appear first.

Common SOAP note documentation mistakes

• Bloated notes. Pasting full lab panels and old imaging reports buries the findings that matter. Summarize and cite.
• Assessment that only repeats the diagnosis. "Hypertension" with no status or reasoning doesn't support the plan.
• Plan items with no matching problem. If you ordered it, the assessment should explain why.
• Missing pertinent negatives. For chest pain, "denies exertional symptoms, no radiation" matters as much as what's present.
• Internal contradictions. An HPI saying "no fever" next to a templated ROS saying "positive for fever" is common with copy-forward.

Copy-ready SOAP note template

• Date/time:
• Visit type: in person / telehealth
• Patient (initials/ID per policy):
• Age/Sex:

S – Subjective

• CC (patient's words):
• HPI (onset, duration, severity, modifying factors, changes since last visit):
• Pertinent ROS (positives and negatives):
• Medications / adherence:
• Allergies:
• Relevant history (PMH, social, family):

O – Objective

• Vital signs:
• Focused exam (systems actually examined):
• Labs / imaging / screening scores (with prior values):

A – Assessment

1. Problem — status (improving / stable / worse) — reasoning
2. Problem — status — reasoning

P – Plan

1. (matches problem 1) Orders, medications with dose and frequency, referrals
2. (matches problem 2)

• Education / shared decision-making:
• Return precautions:
• Follow-up:

From the exam room: The note I'm grateful for at 7 a.m. is the one where the assessment tells me what the last clinician was worried about. I'll forgive a short HPI. I won't easily forgive a plan I can't connect to a problem. Write the assessment as if you're handing the patient off, because eventually you are.

Where AI helps with SOAP note documentation

Most of the time a SOAP note takes goes into turning a conversation into organized text. That's the part an AI medical scribe can draft for you.

Expert AI listens during in-person or telehealth visits, writes a structured SOAP note and suggests ICD-10 codes for you to review. It supports custom note templates and works with most EHRs through a Chrome extension or one-click copy-paste. You review, edit and sign; the AI handles the first draft. Expert AI users save over 2 hours a day on charting.

If privacy is your first question, read our guide to HIPAA-compliant AI transcription. For virtual visits, our telehealth documentation checklist covers what every video visit note needs.

Frequently asked questions

What should be included in SOAP note documentation?

The patient's chief complaint and history, your exam and test results, your assessment of each problem with its status, and a specific plan with follow-up. Pertinent negatives and patient education belong in the note too.

Are SOAP notes legal documents?

Yes. SOAP notes are part of the medical record and can be used in audits, peer review and legal proceedings. Correct errors with a dated addendum, never by editing a signed note.

Is a SOAP note the same as a progress note?

A SOAP note is one format for writing a progress note. Progress notes can also be written as APSO, DAP or narrative notes. SOAP is the most common.

What is the difference between SOAP and APSO notes?

They contain the same information. APSO puts the Assessment and Plan first, so readers see your conclusions before the supporting data.

How long should a SOAP note be?

Long enough to support your assessment and plan, and no longer. A focused follow-up may need only a few lines per section. A new or complex problem needs more history and reasoning.

Where does the diagnosis go in a SOAP note?

In the Assessment. List each problem with its status and a short line of reasoning based on the subjective and objective findings above it.

Better notes, fewer late nights

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