Free SOAP notes template & generator
Fill in a clean SOAP note in seconds, see it formatted live, then download a PDF or copy to your EHR. Built for nurses, physicians, therapists, physiotherapists, and allied health clinicians. Nothing you type ever leaves your browser.
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Privacy: Everything stays in your browser. We do not store, transmit, or log patient data. For HIPAA-conscious workflows, use patient initials and avoid identifying detail in free-text fields.
What is a SOAP note?
SOAP stands for Subjective, Objective, Assessment, and Plan. It is the most widely used structure for clinical progress notes across nursing, medicine, therapy, and allied health. A well-written SOAP note documents what the patient reported, what you observed, how you interpreted it, and what you plan to do next, in a form that another clinician can read and act on without context.
The format dates back to the 1960s and the problem-oriented medical record, but it remains the default in 2026 because it forces the writer to separate fact from interpretation. Subjective and Objective are reporting; Assessment and Plan are clinical reasoning. Mixing them up is the most common reason notes get flagged in audit.
How to write a SOAP note
- Subjective. Capture the patient's chief complaint in their own words, plus a brief history of the present illness, relevant past medical history, allergies, and current medications. Use direct quotes when the wording matters.
- Objective. Record measurable, observable data: vital signs, physical exam findings, lab results, imaging, mental-status observations, and any standardised assessment scores. No interpretation here, just findings.
- Assessment. State your working diagnosis or clinical impression, the differential if relevant, the status of any known conditions, and progress toward treatment goals. This is the section your future self will read first.
- Plan. List concrete next steps: medications prescribed or changed, interventions performed, referrals made, follow-up timing, patient education delivered, and any orders placed. One numbered list per problem keeps it readable.
- Sign and date. Add your name, credentials, and the date and time the note was written. Most EHRs and audit standards require this.
SOAP note example
Here is a fully written outpatient SOAP note for a routine follow-up. Use it as a template for length and specificity, not as clinical advice.
Patient
Subjective
62-year-old male presenting for 3-month follow-up of type 2 diabetes and hypertension. Reports good adherence to metformin 1000 mg twice daily and lisinopril 20 mg daily. Denies polyuria, polydipsia, dizziness, or chest pain. Walking 30 minutes most days. Concerned about occasional numbness in both feet over the past month, worse at night.
Objective
BP 128/78 sitting, HR 72 regular, BMI 28.4. Cardiopulmonary exam unremarkable. Feet: no ulcers, intact pulses, monofilament sensation reduced bilaterally at the great toe. HbA1c (today, point of care) 7.1%, down from 7.6% three months ago. eGFR 78. UACR 12.
Assessment
1. Type 2 diabetes mellitus, improved control on current regimen, but new bilateral peripheral neuropathy concerning for early diabetic polyneuropathy. 2. Hypertension, well-controlled. 3. Overweight, stable.
Plan
1. Continue metformin and lisinopril at current doses. 2. Order EMG and B12 to evaluate neuropathy. Counselled on foot care and daily inspection. Will trial gabapentin 300 mg at bedtime if symptoms persist. 3. Continue current diet and exercise. Repeat HbA1c, lipids, and UACR in 3 months. 4. Annual dilated eye exam due, referral placed today.
SOAP note tips that actually matter
Write the note while the visit is fresh, not at the end of the day. Specificity protects you in audit and gives the next clinician something to work with. Avoid copy-pasting prior notes; bring forward only data that is still true today. Keep the Plan section action-oriented: every line should answer "what is going to happen and when". If your EHR allows, link each Plan item to a problem in the Assessment so billing and quality reporting both fall out cleanly.
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Built for every clinical setting
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Frequently asked questions
What does SOAP stand for in medical notes?
Subjective, Objective, Assessment, and Plan. It is the most widely used structure for clinical progress notes in nursing, medicine, therapy, and allied health.
Is this SOAP notes generator HIPAA compliant?
Nothing you type ever leaves your browser. The form, the live preview, and the PDF are all generated locally on your device, so no patient data is transmitted to or stored on our servers. For added safety, use patient initials rather than full names.
Can I use this template for nursing notes?
Yes. SOAP is the standard format for nursing progress notes. Use Subjective for patient-reported symptoms, Objective for vitals and observations, Assessment for nursing diagnosis or clinical status, and Plan for interventions and follow-up.
How long should a SOAP note be?
Most outpatient SOAP notes run 150 to 400 words. The right length is whatever captures the visit accurately. Avoid copy-pasting prior notes; specifics protect both the patient and the clinician.
Are SOAP notes legally required?
Documentation requirements depend on your jurisdiction, profession, and payer. SOAP itself is not mandated, but a clear progress note for every patient encounter is the universal standard of care and the basis for billing and audit defence.
What is the difference between SOAP and DAP notes?
DAP merges Subjective and Objective into a single Data section, leaving Assessment and Plan as separate sections. DAP is common in mental health and counselling. Use the therapy progress notes generator if you prefer DAP, BIRP, or GIRP.
Can I edit the PDF after I download it?
The downloaded PDF is a flat document. To make changes, edit your inputs in the form and re-download. If you need an editable copy, use the Copy as text button and paste into your EHR or word processor.