Who uses this form
Physicians, nurse practitioners, physician assistants, and allied health clinicians documenting an encounter.
How to use the soap note form
SOAP is a discipline rather than a layout. The value of the format is that it forces a separation between what the patient reported, what was observed, what the clinician concluded, and what happens next - and the most common documentation failure is collapsing those categories into each other.
The Subjective section holds what the patient told you, including the chief complaint in their own words where possible, and the history of present illness. A finding from your own examination does not belong here even though it is tempting to record it while it is fresh.
The Objective section holds what you measured and observed: vitals, examination findings by system, and results available at the encounter. The distinction matters medico-legally as well as clinically, because a note that presents a patient report as an examination finding misrepresents the basis of the diagnosis.
Assessment is the reasoning, not just the label. A diagnosis with no visible reasoning is hard to defend and harder for a colleague to build on. Plan should be specific enough to act on without asking you - dose and duration rather than "start antibiotics", and a named return interval rather than "follow up as needed".
The attestation block is a signature and a date. Where a note may be amended later, knowing when the original was signed is what distinguishes a correction from a rewrite.
Review of systems is optional on this template rather than required, which is deliberate. A ROS completed honestly is valuable; a ROS filled in from a normal template for systems nobody asked about is a documented examination that did not happen, and it is one of the more common findings in a records audit. Making it optional is a nudge toward leaving it blank rather than padding it.
The follow-up field asks for a return interval and the conditions that should prompt an earlier visit. "Follow up as needed" transfers a clinical judgment to a patient who is not equipped to make it, and it is the phrase that appears in notes where a deterioration was missed between appointments.
One note on dictation. SOAP structure suits dictation unusually well, because the four headings give a natural spoken sequence and reduce the tendency to drift between what the patient said and what you found. Dictating immediately after the encounter captures detail that degrades within the hour - but the transcript needs human review before it reaches the chart, because drug names, dosages, and laterality are exactly where automated transcription fails without flagging it.
Every field, explained
15 fields. Required fields are marked; the rest are optional.
Encounter
- Patient NameTextRequired
- Patient this note belongs to
- Medical Record NumberText
- Internal record identifier
- Date of ServiceDateRequired
- Date the encounter took place
- ProviderTextRequired
- Clinician conducting the encounter
Subjective
- Chief ComplaintLong textRequired
- The reason for the visit, in the patient own words where possible
- History of Present IllnessLong textRequired
- Onset, location, duration, character, aggravating and relieving factors, timing, severity
- Review of SystemsLong text
- Pertinent positives and negatives by system
Objective
- Vital SignsLong text
- Blood pressure, pulse, respiration, temperature, oxygen saturation, weight
- Physical ExaminationLong textRequired
- Findings by system examined
- Diagnostic ResultsLong text
- Laboratory, imaging, and point-of-care results available at the encounter
Assessment
- AssessmentLong textRequired
- Diagnosis or differential, with clinical reasoning
Plan
- PlanLong textRequired
- Treatment, prescriptions, referrals, patient education, and return interval
- Follow-UpText
- When the patient should be seen again and under what conditions to return sooner
Attestation
- Provider SignatureSignatureRequired
- Attestation by the clinician who conducted the encounter
- Date SignedDateRequired
- Date of attestation
What a completed form is used for
- Documenting an office or clinic encounter
- Dictating a note immediately after seeing a patient
- Producing a consistent record across multiple clinicians
- Supporting coding and billing with documented reasoning
- Handing over to a colleague who needs the clinical picture quickly
- Establishing a defensible record of the reasoning behind a diagnosis
- Producing the documentation a records audit will examine
SOAP Note questions
What does SOAP stand for?
Subjective, Objective, Assessment, Plan. Subjective is what the patient reports; Objective is what you measure and observe; Assessment is your diagnosis with the reasoning behind it; Plan is what you are doing about it, specifically enough for someone else to carry out.
What is the difference between Subjective and Objective?
Source. Subjective is information from the patient - symptoms, history, what they say happened. Objective is information you produced - vital signs, examination findings, test results. Putting an examination finding in Subjective, or a patient report in Objective, misrepresents where the information came from, which matters if the note is ever scrutinised.
How long should a SOAP note be?
Long enough that a colleague could take over the patient from the note alone, and no longer. Length is not the quality signal; a short note with specific findings and explicit reasoning beats a long one padded with normal-template text that nobody actually examined.
Should normal findings be documented explicitly?
Pertinent negatives yes - recording that you examined a system and found it normal is clinically meaningful and supports the assessment. Wholesale normal-template text for systems nobody examined is a different thing: it documents an examination that did not happen, and it is one of the more common adverse findings in a records audit.
Can I dictate a SOAP note instead of typing it?
Yes, and it is the common approach for high-volume clinics. Dictate immediately after the encounter while detail is fresh, and have the transcript reviewed by a person before it reaches the chart - drug names, dosages, and laterality are exactly where automated transcription fails quietly.
The regulatory information on this page is general background compiled from public primary sources, not legal or compliance advice. Requirements change and vary by jurisdiction and by court. Verify current rules with the relevant authority or your own counsel before relying on them.