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SOAP Note Examples
Eight complete SOAP notes from different disciplines, each written the way a good note should read: the patient's words in Subjective, measurements in Objective, reasoning in Assessment, and a Plan someone else could act on.
What these examples have in common
Each example keeps the patient's account and the clinician's findings apart, measures what it can (pain scores, range of motion, validated questionnaires, vital signs), and ends with a plan that says what happens, how often, and when it will be reviewed.
They are composites written for teaching, not real patients. Adapt the level of detail to your profession's documentation standard and your college's guidance.
Common SOAP note mistakes
Putting interpretation in Subjective ("tight hamstrings" when the patient said "the back of my legs feels stiff"), leaving Objective without numbers, writing an Assessment that only repeats the findings, and closing with a vague Plan such as "continue treatment". Each example below avoids one or more of these.
SOAP Note Examples
Visit
S: Subjective
O: Objective
A: Assessment
P: Plan
Sign-off
Template from zdrovia.ca/templates/soap-note-examples/ · Chart it on a tablet instead, free, at zdrovia.ca · Adapt to your college's documentation standard before use.
Physiotherapy SOAP note example: knee rehabilitation
Week 6 after arthroscopic partial meniscectomy, right knee.
- Subjective
- Reports the knee "feels stronger but still swells after stairs". Pain at rest 1/10, 4/10 after descending two flights. Back at desk work full time. Completing home exercises most days. No locking or giving way.
- Objective
- Mild effusion right knee (stroke test 1+). ROM 0–125° (was 5–110° at week 3). Quadriceps lag nil. Single-leg squat to 45° with mild valgus. KOOS function in daily living 78/100 (was 61). Treatment: progressed to step-downs 3 × 10 and split squats 3 × 8; patellar taping for stairs trialled with less pain.
- Assessment
- Recovering as expected; persistent effusion with eccentric loading limits stair tolerance. Valgus control is the main deficit.
- Plan
- Continue twice weekly for 3 weeks. Add hip abductor strengthening. Ice and elevation after stair-heavy days. Reassess KOOS and single-leg squat at week 9; refer back to surgeon if effusion increases.
Nursing SOAP note example
Community nursing visit, wound care after a fall.
- Subjective
- 78-year-old reports the leg wound is "less sore than last week", pain 3/10, worse at night. Eating and drinking normally. Denies fever or chills. Has not fallen again since the last visit.
- Objective
- Temp 36.8 °C, HR 78, BP 132/76. Skin tear left anterior shin 4.0 × 2.5 cm (was 4.5 × 3.0 cm), 80% granulation, small serous exudate, no odour, peri-wound skin intact, no spreading redness. Dressing changed: silicone contact layer and foam. Morse Fall Scale 45.
- Assessment
- Skin tear healing, no signs of infection. High fall risk persists.
- Plan
- Dressing change every 3 days. Remove the hallway rug and use a night light, discussed with daughter. OT home safety referral sent. Next visit in 3 days; contact the GP if redness spreads, fever develops, or pain increases.
Counselling SOAP note example
Session 4, low mood after job loss.
- Subjective
- Client says the week was "a bit better". Applied for three jobs, went for two walks with a friend. Still waking at 4 a.m. most nights. Denies thoughts of self-harm.
- Objective
- Arrived on time, appropriately dressed, good eye contact, affect brighter than last session. PHQ-9 13 (was 17). Session focused on behavioural activation planning and challenging "I'm unemployable".
- Assessment
- Moderate depressive symptoms, improving with activation. Sleep remains disrupted. Risk assessed as low.
- Plan
- Schedule three pleasant activities and a fixed wake time. Sleep hygiene handout given. Next session in one week; review PHQ-9 at session 6. Safety plan reviewed and on file.
Chiropractic SOAP note example
Follow-up for mechanical neck pain.
- Subjective
- Neck pain 3/10 (was 6/10), mostly after long drives. Headaches down from daily to twice this week. No arm symptoms.
- Objective
- Cervical rotation 70° right, 65° left (was 55° left). Tenderness and restriction C5–6 left. Spurling's negative. Neck Disability Index 16% (was 30%). Treatment: C5–6 mobilisation, soft tissue therapy to left upper trapezius, deep neck flexor exercise reviewed.
- Assessment
- Mechanical neck pain with cervicogenic headache, improving. Left rotation still limited.
- Plan
- Continue weekly for 2 weeks, then reassess. Driving breaks every 45 minutes, chin tucks 3 × 10 daily. Re-score NDI at next review.
Occupational therapy SOAP note example
Home visit after hip replacement.
- Subjective
- Patient worried about getting in and out of the bath. Managing toilet transfers with the raised seat. Wife helps with socks and shoes.
- Objective
- Independent sit-to-stand from the armchair with walker. Bath transfer not attempted (hip precautions). Lower-body dressing needs minimal assistance; long-handled shoehorn and sock aid trialled successfully. Modified Barthel Index 82/100.
- Assessment
- Safe for most ADLs within hip precautions; bathing is the outstanding risk.
- Plan
- Bath board and grab rail ordered. Sponge bathing until installed. Practise sock aid daily. Review in 2 weeks for bath transfer training.
Massage therapy SOAP note example: low back
RMT, new client referred by physiotherapist.
- Subjective
- Low back ache 5/10 after gardening, "tight across the belt line". No leg pain. Seeing physio weekly for exercises.
- Objective
- Increased tone bilateral lumbar erectors and right quadratus lumborum; tender right QL. Lumbar flexion mildly limited by stiffness. Treatment: 45 minutes, prone and side-lying, myofascial release and kneading to lumbar region and gluteals, moderate pressure. Pain after treatment 2/10.
- Assessment
- Muscular low back strain with protective hypertonicity, responding well to treatment.
- Plan
- Heat and gentle walking. Continue physio exercises. Rebook in 10 days. Update to referring physiotherapist sent with client's consent.
Nurse injector SOAP note example: neurotoxin consult
New patient, med spa consultation and first treatment.
- Subjective
- 34-year-old wants to "soften the 11s and forehead lines". No previous neurotoxin. No neuromuscular disorders, not pregnant or breastfeeding, no aminoglycosides. No upcoming events in the next two weeks.
- Objective
- Dynamic glabellar lines moderate, horizontal forehead lines mild, low-set brows. Baseline photos taken at rest and animation. Consent signed. Treatment: onabotulinumtoxinA 20 units glabella (5 sites), 6 units frontalis (kept high), lot and expiry recorded.
- Assessment
- Good candidate. Frontalis dosed conservatively because of low brow position.
- Plan
- Aftercare given verbally and in writing. Review at 2 weeks with photos; touch-up if needed. Next treatment in about 3–4 months.
Telehealth SOAP note example
Video follow-up, dietitian, type 2 diabetes.
- Subjective
- Patient reports "fewer sugar crashes" since moving carbohydrates earlier in the day. Walking 20 minutes after dinner on most days. Finds weekends hardest.
- Objective
- Video visit, identity confirmed, patient at home. Self-reported fasting glucose average 7.4 mmol/L over 7 days (was 8.6). Weight 92.1 kg on home scale (was 93.4). Food log reviewed for 5 days.
- Assessment
- Good progress on meal timing and activity; weekend intake is the main gap.
- Plan
- Plan two weekend meals in advance. Continue post-dinner walks. Next video visit in 4 weeks; patient to bring latest HbA1c result.
Examples are fictional and for illustration only.
Structured notes without the typing
Zdrovia's charting gives you note templates you can adapt to this one, outcome scores that trend across visits, and an AI Scribe that drafts the note from what you say in the room. Everything stays on one patient record, free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for physiotherapy clinics.
Frequently asked questions
What is a good SOAP note example?
One where another clinician could pick up care from the note alone: the patient's own account in Subjective, measured findings and the treatment given in Objective, a short piece of clinical reasoning in Assessment, and a Plan that states what, how often and when it will be reviewed.
How long should each SOAP section be?
A few lines each for a follow-up. Initial assessments run longer because they record the history and baseline measurements for the first time.
Can I copy these SOAP note examples?
Yes, as a model for structure and wording. Write each real note from what happened in that visit, and follow your college's documentation standard.
Related
This template is a documentation aid, not clinical guidance. It records decisions about dosing, depth, and settings; it doesn't make them. Documentation standards vary by province and profession, so adapt it to your regulatory college's requirements.