SOAP Note Template: Copy-Ready Formats for Primary Care, Urgent Care and Mental Health

A SOAP note template gives every visit the same four-part structure: Subjective, Objective, Assessment and Plan. Below you'll find three copy-ready templates (primary care, urgent care and behavioral health), a blank quick-start version and a filled-in example you can model.

Why bother with a template? Because a consistent structure is faster to write, easier for the next clinician to read and simpler to defend in an audit. It also keeps you from forgetting the one element that drives medical necessity, like a pertinent negative or a return precaution.

Copy the format that fits your setting, paste it into your EHR's free-text note or your smart phrase builder, and trim what you don't use. New to the structure? Our SOAP note documentation guide covers the basics.

What a SOAP note template should include

Every good SOAP note template covers the same core elements, whatever the specialty. If you want the reasoning behind each section, our guide to SOAP note documentation best practices walks through all four in detail.

Primary care SOAP note template

Use this for problem-focused and chronic care visits. Delete lines that don't apply rather than writing "N/A" in every field.

S – Subjective

• Chief complaint (in the patient's words):
• HPI: onset, location, duration, character, aggravating/relieving factors, radiation, timing, severity (OLDCARTS)
• Chronic conditions: status since last visit, adherence, side effects
• Pertinent ROS (positives and negatives):
• Past medical / surgical history (updates only):
• Medications reconciled: yes / no; changes:
• Allergies:
• Social history: tobacco, alcohol, substance use, occupation, living situation
• Preventive care due:

O – Objective

• Vitals: BP, HR, RR, temp, SpO2, weight, BMI
• General appearance:
• Focused exam by system (only the systems you examined):
• Point-of-care tests:
• Labs / imaging reviewed (with your interpretation):
• Screening scores (e.g., PHQ-9, GAD-7) if done:

A – Assessment

• Diagnosis 1 (ICD-10): status (controlled / uncontrolled / new), supporting findings
• Diagnosis 2 (ICD-10): status, supporting findings
• Differential considered and why it was ruled in or out:

P – Plan

• Diagnostics ordered:
• Medications started, changed or stopped (dose, route, frequency):
• Non-drug treatment and lifestyle counseling:
• Patient education given and understanding confirmed:
• Referrals:
• Follow-up interval:
• Return precautions:

Urgent care SOAP note template

Urgent care notes need to be short, but they carry more risk: a new patient, no prior relationship and a single chance to document why you sent them home. This template front-loads red flags and disposition.

S – Subjective

• Chief complaint:
• HPI (OLDCARTS), including mechanism of injury if applicable:
• Red-flag symptoms asked about and denied:
• Treatments tried before arrival:
• Relevant history, medications, allergies:
• Last menstrual period / pregnancy possibility (if relevant):

O – Objective

• Triage vitals and repeat vitals if abnormal:
• General appearance and level of distress:
• Focused exam:
• Point-of-care tests (rapid strep, flu/COVID, urinalysis, glucose, pregnancy):
• X-ray or ECG with your read:

A – Assessment

• Working diagnosis (ICD-10):
• Serious causes considered and why they are less likely:

P – Plan

• Treatment given in clinic:
• Prescriptions:
• Work / school note:
• Disposition: discharged home / transferred to ED / referred
• Follow-up with primary care in ___ days
• Specific return precautions given (verbal and written):

Mental health SOAP note template

This version works for psychiatric medication management and behavioral health follow-ups. Counselors and therapists may want the session-focused version in our counseling SOAP note example.

S – Subjective

• Reason for visit / patient's report since last session:
• Mood, sleep, appetite, energy, concentration:
• Medication adherence and side effects:
• Stressors and supports:
• Substance use:
• Suicidal or homicidal ideation (asked directly; patient's response):

O – Objective

• Mental status exam: appearance, behavior, speech, mood (patient's words), affect, thought process, thought content, perception, cognition, insight, judgment
• Standardized measures (PHQ-9, GAD-7, other) with scores:
• Vitals or labs if relevant (e.g., weight, lithium level):

A – Assessment

• Diagnosis (ICD-10) and current status:
• Risk assessment: risk factors, protective factors, overall risk level and reasoning
• Response to current treatment:

P – Plan

• Medication changes:
• Therapy / interventions:
• Safety plan reviewed or updated:
• Coordination with other clinicians:
• Next appointment:
• Crisis resources provided:

Blank SOAP note template (quick version)

For students, quick visits or building your first smart phrase, here is the bare structure.

S – Subjective

• CC:
• HPI:
• ROS:
• PMH / meds / allergies:

O – Objective

• Vitals:
• Exam:
• Results:

A – Assessment

• Diagnosis and reasoning:

P – Plan

• Treatment:
• Education:
• Follow-up:

SOAP note template example: a filled-in urgent care note

Here is the urgent care template filled in for a fictional patient. Notice how short each line is while still covering red flags, reasoning and disposition.

S – Subjective

• CC: "Sore throat for three days."
• HPI: 24-year-old female with 3 days of sore throat, painful swallowing and subjective fever. No cough or nasal congestion. Rates pain 6/10. Ibuprofen gives partial relief.
• Red flags denied: drooling, trouble breathing, voice change, neck stiffness, inability to swallow liquids.
• No known sick contacts. No chronic conditions. Medications: oral contraceptive. Allergies: none known.

O – Objective

• Vitals: T 38.4 °C, HR 96, BP 118/74, RR 16, SpO2 99% on room air.
• General: alert, mild discomfort, speaking in full sentences, tolerating secretions.
• HEENT: tonsils 2+ with exudate, uvula midline, no trismus, no peritonsillar bulge.
• Neck: tender anterior cervical lymphadenopathy, supple.
• Rapid strep antigen: positive.

A – Assessment

• Streptococcal pharyngitis (J02.0). Centor score 4 with positive rapid antigen test.
• Peritonsillar abscess and epiglottitis considered; less likely given midline uvula, no trismus, normal voice and no drooling.

P – Plan

• Amoxicillin 500 mg PO twice daily for 10 days.
• Ibuprofen or acetaminophen as needed for pain and fever.
• Off work for 24 hours after starting antibiotics; work note provided.
• Discharged home. Follow up with primary care if not improving in 48–72 hours.
• Return precautions: trouble breathing, drooling, inability to swallow liquids, muffled voice or worsening one-sided throat pain. Patient verbalized understanding.

How to adapt a SOAP note template to your practice

1. Start with your top five visit types. Build one template per common visit (hypertension follow-up, URI, annual physical, anxiety follow-up) before trying to cover everything.
2. Keep pertinent negatives as prompts. A line like "Red flags denied:" reminds you to ask and document them every time.
3. Avoid pre-filled normal exams. Templates that auto-insert a full normal exam create notes that contradict the HPI. Document only what you examined.
4. Put follow-up and return precautions in the plan by default. They're the most common omissions and matter most in a chart review.
5. Review your templates once a year. Update them for new screening guidance, payer documentation rules and your own habits.

Common SOAP note template mistakes

• Copy-forward text that no longer matches the patient's current status.
• An Assessment that restates the chief complaint instead of giving a diagnosis and reasoning.
• A Plan with "follow up as needed" and no specific interval or precautions.
• Templates so long that clinicians skip fields instead of reading them.

From the exam room: I keep my templates short on purpose. The fields that earn a spot are the ones I'd regret leaving out: red flags asked, the reasoning behind the diagnosis and exactly when the patient should come back. Everything else can be free text.

Where AI helps

A template gives you the structure, but you still have to fill it in, usually after the visit. That's where most charting time goes. We compare the options in our post on AI transcription vs. traditional documentation methods.

Expert AI listens during the visit and drafts a structured SOAP note in the same Subjective, Objective, Assessment and Plan format, with suggested ICD-10 codes for the Assessment. It learns your documentation style over time, and the finished note goes into virtually any EHR through a Chrome extension or one-click copy-paste. It can also email the patient their instructions at the end of the visit. You review and sign every note.

Because visit audio contains protected health information (PHI), privacy matters. Expert AI is a HIPAA-compliant AI medical scribe: it signs a Business Associate Agreement (BAA), encrypts data in transit and at rest, and never uses PHI to train AI models. For a vendor checklist, read Is AI transcription HIPAA compliant?

Frequently asked questions

What is a SOAP note template?

A SOAP note template is a pre-built outline of the four SOAP sections (Subjective, Objective, Assessment and Plan) with prompts for the details each section should contain. Clinicians fill it in for each visit so notes stay complete and consistent.

How long should a SOAP note be?

As long as it needs to be to support the diagnosis, plan and level of service, and no longer. A focused urgent care visit may fit in half a page, while a new complex patient needs more. Completeness and clear reasoning matter more than length.

Are SOAP notes legal documents?

Yes. SOAP notes are part of the medical record, which can be requested in audits, payer reviews and legal proceedings. That's why accurate, timely and signed documentation matters.

Can I use a SOAP note template in Word or Google Docs?

You can draft a template in Word or Google Docs, but don't store patient information there unless your organization has approved it for PHI. In practice, most clinicians paste the template into their EHR as a smart phrase or note template.

Is there a SOAP note template for nurse practitioners?

The primary care template above works for nurse practitioners, physicians and physician assistants alike. The SOAP structure is the same across roles; what changes is the depth of the exam and the complexity of the plan.

What is the difference between a SOAP note and a progress note?

A progress note is any note documenting a patient's status during ongoing care. SOAP is one of the most common formats for writing a progress note, so many progress notes are SOAP notes.

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