Templates · Free template · Clinical notes
SOAP Note Template
A printable SOAP note template with prompts for each section, plus filled-in examples for physiotherapy, massage therapy, and an aesthetics follow-up. Use it as a paper chart, a teaching aid, or the structure for your digital notes.
What SOAP stands for
SOAP stands for Subjective, Objective, Assessment, and Plan. It is a way of ordering a clinical note so that anyone reading it, including you in six weeks, can see what the patient reported, what you found, what you concluded, and what happens next, in that order.
Subjective is the patient's account: the reason for the visit, symptoms in their words, history, and how things have changed since last time. Objective is what you observed and measured: vital signs, range of motion, test results, scores, photos, and what treatment you performed. Assessment is your clinical reasoning, connecting the two into an impression or a change in status. Plan is what you will do: treatment, home care, referrals, and when you will see them again.
How to write a SOAP note that's useful later
Keep the patient's words in Subjective and your findings in Objective. The most common mistake is mixing the two, for example writing "tight upper traps" in Subjective when the patient actually said "my shoulders feel stiff by the afternoon". The distinction is what lets the note stand up as a record.
Measure whatever you can. "Pain improved" says very little; "worst pain 6/10 last week, 3/10 this week" lets you and the next practitioner see a trend. Validated outcome measures, range-of-motion angles, and repeated scores belong in Objective for the same reason. And make the Plan specific enough to act on: what, how often, and when you'll reassess.
Documentation expectations in Canada
Regulated health professionals in Canada are expected by their colleges to keep a clinical record for every visit, written at or close to the time of the encounter, legible, dated, and attributable to the person who wrote it. Retention periods and specific content requirements are set by each college, so check your own standard of practice.
Corrections should be visible: strike through and initial on paper, or use an amendment that keeps the original on a digital system. Never overwrite an earlier entry.
SOAP Note
Visit
S — Subjective
Reason for visit, symptoms in the patient's words, onset and history, aggravating and easing factors, changes since last visit, relevant medications.
O — Objective
Observations, vital signs, measurements, test results, outcome scores, photos taken, and treatment performed.
A — Assessment
Your clinical impression, progress against goals, and anything that changes the working diagnosis.
P — Plan
Treatment going forward, home care or exercises, education given, referrals, and when you'll reassess.
Sign-off
Template from zdrovia.ca/templates/soap-note-template/ · Adapt to your college's documentation standard before use.
Physiotherapy SOAP note example
Follow-up visit for mechanical low back pain.
- Subjective
- 42-year-old office worker, third visit. Low back pain since lifting a box three weeks ago. Reports worst pain this week 4/10 (was 6/10 at initial visit), mostly after sitting more than 40 minutes. Walking 20 minutes daily as advised. Denies leg symptoms, numbness, bladder or bowel changes, or night pain.
- Objective
- Lumbar flexion to mid-shin with end-range discomfort (was knee level). Straight leg raise negative bilaterally. Neurological screen normal. Tender L4–5 paraspinals, reduced from last visit. Oswestry Disability Index 22% (was 34%). Treatment: lumbar mobilisation grade III, 3 × 30 s; progressed exercise program to include bridging and bird-dog.
- Assessment
- Mechanical low back pain without radicular features, improving as expected. Sitting tolerance remains the main functional limit. No red flags.
- Plan
- Continue walking and home program, add sitting breaks every 30 minutes at work. Review in one week; aim to discharge to self-management within three visits. Refer to physician if leg symptoms or red flags develop.
Massage therapy SOAP note example
Registered massage therapist, returning client with neck and shoulder tension.
- Subjective
- Client reports neck and upper shoulder tension, worse at the end of the workday, with two tension-type headaches this week (previously four). Rates tension 5/10. New standing desk since last visit.
- Objective
- Elevated right shoulder at rest. Hypertonicity and tenderness in right upper trapezius and levator scapulae; trigger point in right upper trapezius reproducing familiar temple ache. Cervical rotation right limited compared with left. Treatment: 60 minutes, Swedish techniques to neck, shoulders and upper back, trigger point release to right upper trapezius, client tolerated well; pressure moderate by client preference.
- Assessment
- Postural muscle tension with myofascial trigger points contributing to headaches. Headache frequency and tension improving since the last visit.
- Plan
- Home care: heat 15 minutes after work, upper trapezius and levator stretches twice daily, screen height review. Rebook in two weeks. Recommend physician follow-up if headaches change in pattern or intensity.
Aesthetics SOAP note example
Two-week neurotoxin review in a med spa.
- Subjective
- Patient pleased with forehead and glabella. Notices a little remaining movement at the outer edge of the left eye when smiling. No bruising, headache, or eyelid heaviness reported.
- Objective
- Follow-up photos taken and compared with baseline in the same lighting and position. Glabella and frontalis movement reduced symmetrically. Mild residual contraction left lateral orbicularis oculi on animation; right side smooth. No ptosis.
- Assessment
- Good overall response with minor asymmetry at left lateral crow's feet.
- Plan
- Touch-up to left lateral crow's feet per injector assessment; product, units, sites, and lot recorded on the neurotoxin treatment record. Aftercare reviewed. Next full treatment in about three months.
Examples are fictional and for illustration only.
Let the SOAP note write itself
Zdrovia includes SOAP note templates for consults, follow-ups, and treatment visits. The AI Scribe listens during the appointment and fills the note's structured fields, so scores and measurements stay as data you can graph across visits, not a paragraph you have to reread. Included on every plan, free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for physiotherapy clinics.
Frequently asked questions
What does SOAP stand for in a clinical note?
Subjective, Objective, Assessment, and Plan. Subjective is what the patient reports, Objective is what the clinician observes and measures, Assessment is the clinical impression, and Plan is the next steps.
What's the difference between subjective and objective?
Subjective is the patient's own account, recorded in or close to their words. Objective is what you can observe, measure, or test, such as range of motion, vital signs, outcome scores, or photos. Keeping them separate is what makes the note reliable later.
How long should a SOAP note be?
Long enough that another clinician could safely continue care from it, and no longer. Follow-up notes are often a few lines per section. Initial assessments are longer because the history and baseline measurements are recorded for the first time.
Can AI write SOAP notes?
AI scribes can draft a note from the conversation, which saves a lot of typing. The clinician is still responsible for the content, so review and edit the draft before signing it. Zdrovia's AI Scribe is included on every plan and fills the structured fields of the chart rather than producing a block of text.
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.