Healthcare professionals spend 15-20 minutes per patient on documentation—that’s over 6 hours daily for physicians seeing 25+ patients. SOAP notes are the gold standard for clinical documentation, but they don’t have to consume your day.
This guide provides practical SOAP note examples across key specialties and proven strategies to reduce documentation time by 70%.
What Are SOAP Notes?
SOAP notes are a standardized documentation method with four components:
- Subjective: Patient’s reported symptoms and history
- Objective: Measurable clinical findings (vitals, exam, labs)
- Assessment: Your diagnosis and clinical reasoning
- Plan: Treatment steps and follow-up
Primary Care SOAP Note Example
Patient: 45F, annual wellness visit
S: No acute complaints. Exercises 3x weekly. Non-smoker. Family history: mother with breast cancer at 58, father with T2DM.
O: BP 122/78, HR 72, BMI 24.5. General: Well-appearing. HEENT: Normal. Cardiac: RRR, no murmurs. Lungs: Clear. Labs: Lipids – LDL 115, HDL 58. HgA1c 5.4%.
A: 1) Health maintenance appropriate. 2) Borderline hyperlipidemia. 3) Breast cancer screening due (family history).
P: 1) Continue lifestyle modifications. 2) Recheck lipids in 6 months. 3) Screening mammogram ordered. 4) Tdap given. 5) Return 1 year.
Mental Health SOAP Note Example
Patient: 28M, depression follow-up
S: “Feeling better.” Sleep improved 4-5h to 6-7h since starting sertraline 3 weeks ago. Denies SI. Attending all work shifts (previously missing 2-3 days weekly). PHQ-9: 12 (down from 18).
O: Mood: “Better, hopeful.” Affect: Brighter, increased eye contact. Speech/thought: Normal, organized. SI/HI: Denied.
A: Major Depressive Disorder, moderate, responding well to sertraline + CBT. PHQ-9 decreased 6 points. Low suicide risk.
P: 1) Continue sertraline 50mg daily. 2) Weekly CBT. 3) Homework: Daily walks, add social activity. 4) Safety plan reviewed. 5) Return 1 week.
Pediatric SOAP Note Example
Patient: 6M, fever and cough
S: Fever x2 days, max 102.5°F. Barky cough worse at night. Runny nose x3 days. History: Mild intermittent asthma.
O: Temp 100.8°F, RR 24, O2 sat 97%. Alert, playful. TMs: Bilateral erythema. Lungs: Mild expiratory wheeze, stridor with agitation only.
A: 1) Viral croup, mild-moderate. 2) Asthma exacerbation, mild.
P: 1) Dexamethasone 13mg PO x1. 2) Albuterol 2 puffs q4-6h PRN. 3) Ibuprofen PRN. 4) Cool mist humidifier. 5) Return precautions given. 6) Follow up 24-48h.
Emergency Medicine SOAP Note
Patient: 62M, chest pain
S: Crushing substernal chest pain x45min while shoveling snow. 9/10, radiates to left arm/jaw. Diaphoresis. PMH: HTN, HLD, T2DM. Smokes 1PPD x40yr.
O: BP 160/95, HR 110. Diaphoretic, anxious. EKG: ST elevation 3mm II, III, aVF. Troponin: 1.2 (elevated).
A: Acute STEMI, inferior wall.
P: STEMI protocol. 1) Cardiology consult. 2) ASA 325mg, Plavix 600mg, heparin drip. 3) O2 2L. 4) To cath lab, door-to-balloon <90min.
Physical Therapy SOAP Note
Patient: 55F, knee OA, Session 4/8
S: Pain decreased 6/10 to 4/10. Can walk 15min (previously 10min). AM stiffness 20min (was 45min). Completed HEP 5 days. “Can grocery shop without limping.”
O: Gait: Normal, no antalgic. ROM: Flexion 125° (was 115°), Extension -2° (was -5°). Strength: Quads 4/5 (was 3+/5). 6MWT: 425m (was 350m).
A: Excellent progress. Pain down 2 points, ROM improved 10° flexion, strength up half grade. On track for 30min walking goal.
P: 1) Progress exercises. 2) Add step-ups. 3) Single leg balance on unstable surface. 4) Updated HEP. 5) Return 3 days.
Nursing SOAP Note Example
Patient: 72M, post-op day 2, hip replacement
S: Pain 5/10 at surgical site. “Hurts when I move but medicine helps.” Passed flatus this AM. Anxious about PT. “Worried I’ll fall.”
O: BP 132/78, Temp 99.1°F, Pain 5/10. Dressing dry/intact. Pedal pulses 2+. Voided 300cc post-Foley removal. PCA functioning.
A: Post-op recovery progressing. Pain controlled. Surgical site clean. Neurovasc intact. Low temp post-surgical. Anxious but stable for PT.
P: 1) Continue PCA, transition to PO tomorrow. 2) Premedicate 30min before PT. 3) Fall precautions. 4) Monitor surgical site. 5) DVT prophylaxis. 6) Bowel regimen started.
5 Time-Saving SOAP Note Strategies
1. Use Templates
Create customized templates for common visit types. Use EHR “dot phrases” for standard text—”.normalphysical” expands to your full normal exam.
2. Document During Visits
Chart in real-time to reduce memory burden. Position your screen to maintain eye contact while typing key points.
3. Structured Data Entry
Use checkboxes and dropdowns for Review of Systems and Physical Exam. Faster than free text and improves billing.
4. Voice Recognition
Medical speech recognition reduces typing time 60-70%. Dragon Medical One learns your patterns.
5. Ambient AI Documentation
The game-changer: AI medical scribes listen to patient conversations and auto-generate SOAP notes in under 60 seconds—a 90% time savings.
Common SOAP Note Mistakes
- ❌ Incomplete HPI: Document full OLDCARTS, not just “patient has chest pain”
- ❌ Mixing S and O: Vital signs always go in Objective, never Subjective
- ❌ Vague assessments: Show clinical reasoning, not just diagnosis labels
- ❌ Non-specific plans: Include drug/dose/duration, not just “prescribe antibiotic”
- ❌ Copy-forward: Always update Assessment and Plan for current visit
- ❌ No follow-up: Document when to return and warning signs
HIPAA Compliance for SOAP Notes
SOAP format is HIPAA-compliant, but HOW you create notes matters:
- ✅ Use encrypted, secure systems
- ✅ Implement audit trails
- ✅ Require Business Associate Agreements for vendors
- ✅ Maintain proper retention (6-10 years)
- ❌ Never use consumer AI like ChatGPT (not HIPAA-compliant)
- ❌ Don’t email unencrypted patient data
Can AI Write SOAP Notes?
Consumer AI (ChatGPT): No. Not HIPAA-compliant, can’t listen to encounters, may hallucinate details.
Medical-specific AI: Yes. Purpose-built tools like NoteV offer:
- ✅ HIPAA compliance with BAA
- ✅ 99% accuracy across 50+ specialties
- ✅ Ambient listening during encounters
- ✅ Direct EHR integration
- ✅ Physician review before signing
FAQ
Who uses SOAP notes?
Physicians, NPs, PAs, nurses, therapists, psychologists, social workers, and most healthcare professionals.
How long should a SOAP note be?
Simple visits: 1/2 page. Complex cases: 2-3 pages. Focus on thoroughness, not length.
Are SOAP notes legally required?
Not specifically, but comprehensive documentation IS required for billing, compliance, and legal protection.
Can I use abbreviations?
Only approved institutional abbreviations. Never use Joint Commission “Do Not Use” list items.
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References: Podder V, et al. SOAP Notes. StatPearls 2023. | AMA Clinical Documentation Standards | CMS E/M Guidelines | HHS HIPAA Privacy Rule