SOAP note examples
Seven complete SOAP notes, one per profession, each with what makes it work and what to include in each section. The patients and clients are fictional; the documentation follows what each profession records.
Examples by specialty
Counseling and therapy
A complete therapy SOAP note example for an anxiety client, with risk assessment, GAD-7 scores and a CBT plan, and what to include in each section.
Read the examplePhysical therapy
A complete physical therapy SOAP note example after knee surgery, with range of motion, strength, LEFS, interventions and goals, and what each section needs.
Read the exampleChiropractic
A complete chiropractic SOAP note example for neck pain, with PART findings, segmental levels, the adjustment and NDI scores, and what each section needs.
Read the exampleOccupational therapy
A complete occupational therapy SOAP note example after a stroke, with grip strength, Nine-Hole Peg Test, ADL training and goals, and what each section needs.
Read the exampleSpeech therapy
A complete speech therapy SOAP note example for a child with a phonological disorder, with accuracy per target, cues and goals, and what each section needs.
Read the exampleDietitian
A complete dietitian SOAP note example for type 2 diabetes, with a diet recall, weight, A1c, a PES statement and goals, and how it maps to ADIME.
Read the exampleMassage therapy
A complete massage therapy SOAP note example for a runner, with palpation findings, techniques, pressure, before-and-after measures and self-care.
Read the example
Write your own
The free SOAP note template has prompts for each of these professions. Fill it in and download a PDF, made on your device.
Open the SOAP note templateSOAP notes in CloudMedico
CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.
Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.
Try CloudMedico free for 30 daysThe four parts of a SOAP note
- Subjective: what the client reports, in their words where it matters.
- Objective: what you observe, measure and do in the session.
- Assessment: what you make of it, and progress toward the goals.
- Plan: what happens next, and when you'll reassess.
What every good example has in common
- Numbers that can be compared from visit to visit: ratings, measurements and standardized scores.
- An Assessment that refers back to the goals and says whether each is met, progressing or not.
- The treatment given, how long it took, and how the client responded.
- A Plan someone else could carry out: frequency, next steps, home program and the date of the next reassessment.
Questions
Are these real patient notes?
No. Every patient and client in these examples is fictional, and any likeness to a real person is a coincidence. The findings, measures and plans are written to be clinically sound for each profession.
How long should a SOAP note be?
Long enough that another clinician could pick up the care from it, and no longer. A follow-up note is often 150 to 300 words; an evaluation or a progress report is longer.
Can I copy these examples?
Use them to see what to include, then write your own note from your own session. A note copied from a template rather than from the visit can be challenged in an audit.