Clinical template
SOAP Note Template with Examples
A SOAP note records one encounter in four blocks: Subjective, Objective, Assessment, and Plan. Use the blank below, then look at three fictional Canadian cases written the way a family physician would chart them after a 15-minute visit.
Blank SOAP template
Copy this into your EMR, a Word doc, or a Scribeberry custom template. Number problems when the visit covers more than one issue, and carry the same number through Assessment and Plan.
SOAP note
Date / time: Clinician / location: Patient: [initials, age, sex] | Visit type: in-person / virtual / phone S — Subjective CC: HPI (onset, location, duration, character, aggravating/relieving, radiation, timing, severity, associated symptoms, treatments tried): Pertinent PMHx / PSHx: Meds / allergies: Social / function (work, smoking, alcohol, caregiving): ROS (pertinent positives and negatives only): O — Objective Vitals: BP HR RR Temp SpO2 Weight/BMI Exam (by system, abnormal first): Point-of-care / labs / imaging available today: A — Assessment Problem 1: [working diagnosis] — [brief reasoning / red flags considered] Problem 2: P — Plan Problem 1: investigations / treatment / counselling / follow-up / safety-net Problem 2: Prescriptions issued: Forms / letters / referrals generated:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, billing rules, or your own clinical judgment. Review every generated note before it enters the chart.
What each letter is for
Lawrence Weed introduced the problem-oriented medical record in the 1960s. SOAP is the encounter-level format that grew out of that work. The point is not the acronym. The point is that the next clinician, including you at 11 p.m. three weeks from now, can see what the patient said, what you measured, what you thought, and what you did.
| Section | What belongs here | What does not |
|---|---|---|
| Subjective | Patient (or caregiver) narrative: CC, HPI, meds, allergies, function, pertinent ROS | Your diagnosis, vitals, or exam findings |
| Objective | Vitals, exam, point-of-care tests, results you have in hand today | History you were told, or a plan you have not executed |
| Assessment | Working diagnosis, differentials you actually considered, uncertainty | A restatement of the HPI with no synthesis |
| Plan | Orders, prescriptions, counselling done, follow-up, safety-net, forms | Vague 'follow up PRN' with no trigger or timeframe |
Canadian charts often keep a Cumulative Patient Profile (CPP) for meds, problems, and allergies. If the CPP is current, write 'meds/allergies as per CPP' in Subjective rather than pasting a 14-drug list into every SOAP. If you changed a drug today, name the change in Plan and update the CPP in the same sitting.
How to write each section
Subjective starts with the chief complaint in the patient's words when that is useful ('my back seized at work'), then an HPI. OLDCARTS or OPQRST both work. For multi-problem visits, number the complaints here so Assessment and Plan can reuse the numbers. Pertinent negatives belong in the HPI, not in a 12-system ROS dump.
Objective leads with vitals. Exam is abnormal-first, then the relevant normals that rule something out. 'CNS grossly intact' is fine for an uncomplicated UTI. It is not fine for new headache with weight loss. Put today's glucometer reading, urine dip, or strep swab here. Yesterday's A1c belongs in Assessment as context, or in the CPP, not mixed into today's exam.
Assessment is the sentence you would say out loud to a colleague. 'Acute mechanical low back pain, no red flags today' is an assessment. 'Patient has back pain' is not. Name the leading diagnosis, the two things you ruled out and why, and any uncertainty you are still carrying.
Plan is executable. Drug, dose, duration. Test, and who calls whom with the result. Time to follow-up. Safety-net symptoms that send the patient to ED rather than the after-hours line. If you completed a WSIB Form 8, a sick note, or a referral, list it here so the chart shows the paperwork trail.
Example 1 — acute low back pain
Family medicine, in-person
38-year-old warehouse worker, Edmonton. 12-minute visit. Fictional.
S CC: "I lifted a pallet yesterday and my lower back locked." HPI: 38M, sudden lumbosacral pain while lifting ~25 kg at work yesterday 14:00. Pain 7/10, dull, worse bending and sitting, better recumbent. No radiation below the knee, no saddle anesthesia, no bowel/bladder change, no fever, no unexplained weight loss, no IV drug use, no cancer history. Slept poorly. Ice and extra-strength acetaminophen with partial relief. No prior imaging. Similar strain 4 years ago, resolved in 10 days. PMHx: none. Meds: none. NKDA. Work: full duties warehouse, repetitive lifting. Non-smoker. O Vitals: 128/78, HR 76, RR 16, T 36.6, SpO2 98% RA. Exam: walks in, antalgic. No midline bony tenderness. Paraspinal spasm L4–S1. SLR negative bilaterally. Power, sensation, reflexes intact L4–S1. Abdominal exam soft. No fever. A 1. Acute mechanical lumbar strain, occupational. No cauda equina or infection red flags today. 2. Work injury — Form 8 indicated. P 1. Stay active; avoid prolonged bed rest. Acetaminophen 1 g PO q6h PRN (max 4 g/day) and ibuprofen 400 mg PO q6h PRN with food x 5 days if no GI/renal contraindication. Heat, gentle mobility. No imaging today (Choosing Wisely: no red flags, <4 weeks). 2. Off modified duties discussion: no lifting >10 kg x 7 days, then reassess. WSIB Form 8 completed. RTC 7 days or sooner if saddle anesthesia, bilateral leg weakness, or urinary retention — ED same day. Counselling: expected improvement over 1–2 weeks; return if night pain or fever.
Example 2 — diabetes and blood pressure follow-up
Chronic disease visit
62-year-old woman, Toronto. 20-minute booked follow-up. Fictional.
S CC: "I'm here for my sugars and blood pressure." HPI: 62F with T2DM (2018) and hypertension. Home glucose fasting 7.8–9.2 last 2 weeks (log reviewed). No polyuria, polydipsia, or nocturnal hypoglycemia. Adherent to metformin. Missed ramipril 4 days last month while travelling. Foot care: self-checks, no new ulcers. Ophthalmology last 8 months, no retinopathy. Non-smoker. Walks 20 min most days. Meds/allergies: as per CPP (metformin 1000 mg BID, ramipril 10 mg daily, atorvastatin 20 mg daily). NKDA. O Vitals: 148/88 (repeat 144/86), HR 72, BMI 31.2, weight 84.4 kg (+1.1 kg / 6 mo). Exam: heart sounds dual, no edema. Feet: pulses present, monofilament intact 10/10, skin intact. Labs (on chart, drawn 8 days ago): A1c 7.8% (was 7.3%), eGFR 78, ACR 1.4, LDL 1.9, K 4.3, Cr 71. A 1. T2DM — A1c above 7.0% target discussed previously; no hypoglycemia. 2. Hypertension — above 130/80 diabetes target, likely missed doses plus weight creep. 3. CV risk modifiers otherwise at target (statin, non-smoker). P 1. Continue metformin. Add empagliflozin 10 mg PO daily (eGFR ok; counsel genital hygiene, sick-day hold, euglycemic DKA symptoms). Recheck A1c and ACR in 3 months. Refer diabetes education if she wants a group class. 2. Restart ramipril daily without misses; home BP log x 2 weeks, RTC if home average >135/85. No ACE/ARB + SGLT2 sick-day hold written on wallet card. 3. Dietitian referral for weight. Foot care reinforced. Influenza vaccine offered, declined today. Prescriptions issued. Follow-up 8 weeks.
Example 3 — pediatric otitis media
Pediatrics, after-hours clinic
3-year-old, Calgary. Parent present. Fictional.
S CC: "He's been pulling at his right ear and feverish since last night." HPI: 3M, 18 hours of right ear pain, fever to 38.9 at home, poorer sleep, drinking well, wet diapers normal. No vomiting, no stiff neck, no rash, no difficulty breathing. Daycare. Recurrent AOM x 2 in past 12 months, last episode 5 months ago. Immunizations up to date per CPP. No tubes. No drug allergies. Weight last visit 14.8 kg. O Vitals: T 38.4 (ax), HR 118, RR 24, SpO2 99%, weight 15.0 kg. Exam: alert, interactive, no respiratory distress. Right TM bulging, erythematous, poor mobility; left TM normal. Oropharynx mildly injected, no exudate. Neck supple. Chest clear. No rash. A Acute right otitis media. No mastoid tenderness, no toxic appearance. Meets criteria for immediate antibiotics (age <6 months would be automatic; here age 3 with 18 h fever + moderate pain). P Amoxicillin 90 mg/kg/day divided BID x 5 days (675 mg PO BID; suspension). Ibuprofen 10 mg/kg q6h PRN. Return if persistent fever >48 h on antibiotics, swelling behind the ear, or lethargy. Recheck only if symptoms persist at end of course. Daycare letter provided. Safety-net: ED for neck stiffness, rash, or work of breathing.
Mistakes that show up in charts
- Copy-forwarding last visit's exam as if you performed it today.
- Putting the diagnosis in Subjective ('patient here for UTI') before you have findings.
- Assessment that only restates the CC.
- Plan with no dose, no duration, and no owner for results.
- Missing safety-net on presentations that can still go wrong overnight (headache, back pain, fever in a toddler).
- Writing a novel ROS that is unrelated to the complaint, then missing the one pertinent negative that mattered.
CMPA's documentation advice is consistent across provinces: if it is not in the record, it is hard to show it happened. Colleges also expect you to correct the chart when the generated note is wrong. An AI draft does not change who signs.
SOAP vs DAP, BIRP, and narrative
DAP (Data, Assessment, Plan) collapses S and O. Mental health teams often prefer it for therapy follow-ups. BIRP (Behavior, Intervention, Response, Plan) is common in counselling. Narrative consult letters still need the same four ideas even if you never label them SOAP. If your EMR template is 'progress note' with free text, keep the order anyway: what they said, what you found, what you think, what you will do.
Generate the SOAP from the visit
Scribeberry listens to the encounter, or takes dictation, and drafts the four sections in your template. Edit, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a SOAP note?
A SOAP note is a clinical encounter record split into Subjective (the patient's story), Objective (exam and measurements), Assessment (your synthesis), and Plan (orders, treatment, follow-up). Dr. Lawrence Weed popularized the format as part of the problem-oriented medical record.
How long should a SOAP note be?
Long enough that another clinician can reconstruct the decision, short enough that you could have written it before the next patient sat down. Uncomplicated acute visits often fit in half a page. Multi-problem chronic visits run longer because each numbered problem needs its own A and P.
Can I use SOAP notes for billing in Canada?
SOAP itself is not a billing code. Provincial schedules pay for the service you provided. The note has to support medical necessity and the level of the visit. Keep time, complexity, and procedures in Plan or a billing addendum if your billing staff need them.
Does Scribeberry write SOAP notes automatically?
Yes. Pick a SOAP template (or your own headings), record or dictate the visit, and generate. You review and edit before the note goes to the EMR. Custom templates and memories keep headings in your voice.
Templates
