Free SOAP note template
Pick your profession to see prompts for each section, write your note under Subjective, Objective, Assessment and Plan, and download it as a PDF. Or download a blank template with the prompts printed, to fill in by hand.
Your SOAP note
What you type stays in this browser. The PDF is made on your device, and nothing you write is sent to CloudMedico or saved. Closing or reloading the page clears the note.
- Reason for the visit, in the client's words
- Symptoms: onset, location, severity (0–10), what makes them better or worse
- Changes since the last visit; home program or homework done
- Medications, allergies or health history changes
- Goals and concerns
- Observations: appearance, behavior, posture, movement
- Measurements and standardized test scores, with the last result for comparison
- Treatment or interventions given, and minutes for each
- How the client responded
- Diagnosis or problem, with ICD-10-CM codes if you bill
- Progress toward each goal: met, progressing or not progressing
- What still limits the client
- Why your care is still needed
- Frequency and duration of care
- What you'll do next session
- Home program, homework or education given
- Referrals and coordination with other providers
- Next reassessment and next appointment
SOAP 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 daysWhat a SOAP note is
A SOAP note is a structured record of one visit or session in four parts: Subjective, Objective, Assessment and Plan. The format comes from Dr. Lawrence Weed's problem-oriented medical record of the 1960s, and it is now how most US clinicians, therapists and bodyworkers write progress notes.
The order follows how you think through a visit: what the client tells you, what you observe and measure, what you make of it, and what happens next. Anyone who picks up the chart, whether a colleague, a covering clinician or an insurer's reviewer, can find each part in the same place.
What goes in each section
- Subjective: what the client or their caregiver reports. Symptoms in their own words, pain or distress ratings, how they've been since the last visit, what they did at home, their goals, and any change in medications or health history.
- Objective: what you observe, measure and do. Measurements and test scores, observations, the treatment or interventions you gave and for how long, and how the client responded.
- Assessment: your clinical judgment. The diagnosis or problem, progress toward each goal compared with the last measurement, what still limits the client, and why your care is still needed.
- Plan: what happens next. Frequency and duration of care, what you'll do next session, home program or homework, referrals and coordination, and when you'll reassess.
How to write a good SOAP note
- Write it the same day, ideally right after the session, while details are fresh.
- Put numbers on what you can: pain on a 0–10 scale, range of motion in degrees, a standardized score, accuracy as a percentage of trials.
- Compare with the last measurement, so progress can be read from the note alone.
- Let the Assessment follow from Subjective and Objective: no new facts appear there for the first time.
- Make the Plan specific: what, how often, until when, and what would change it.
- Keep the wording factual and respectful. The client may read the note, and under federal rules they have the right to ask for a copy.
- Sign and date it, with your credentials.
Questions
Is this SOAP note template free?
Yes. There's no account and no limit. Fill in the note and download it as a PDF, or download the blank template with prompts to print and fill in by hand.
Is what I type sent anywhere?
No. The note lives in this page in your browser, and the PDF is made on your device. Nothing you type is sent to CloudMedico or kept after you close the page. Store the PDF the way your practice stores other clinical records.
Does the template write the note for me?
No. The prompts remind you what each section usually holds for your profession; the note is yours. For worked examples, see the SOAP note examples for each specialty.
Can I use SOAP notes for insurance billing?
SOAP notes are the usual way to document services that insurers pay for, including Medicare. What a payer needs differs by payer and profession, so check your payer's documentation rules and your licensing board's requirements.
What's the difference between SOAP, DAP and BIRP notes?
They are all progress note formats. DAP (Data, Assessment, Plan) puts subjective and objective information together under Data. BIRP (Behavior, Intervention, Response, Plan) is common in behavioral health and centers on the interventions. SOAP keeps what the client reports apart from what you observe.