What is a SOAP Note? Complete Guide to Writing SOAP Notes in 2025

Writing patient notes takes up a big chunk of your day. Between remembering what the patient said, tracking what you observed, and making sure your notes meet billing standards, it’s easy to feel overwhelmed.

The SOAP note format makes it easier to structure everything clearly, and without leaving out key details.

A SOAP note is a standardized medical documentation format that organizes patient information into four sections: Subjective, Objective, Assessment, and Plan.

In this article, we'll cover what a SOAP note is, what format you should use when writing one, how to write one effectively, and even how to generate them with AI in 2025.

What is a SOAP Note? What Does 'SOAP' Stand For?

A SOAP note is a structured format used by healthcare professionals to document patient visits. It helps organize information clearly so that anyone reviewing the note can understand the patient's condition, what was observed, and what actions were taken.

Here's what 'SOAP' stands for:

• Subjective – What the patient reports, including symptoms, history, and concerns.

• Objective – What the provider observes through exams, measurements, or test results.

• Assessment – The provider’s clinical evaluation or diagnosis based on the subjective and objective information.

• Plan – The recommended next steps, such as treatments, tests, or follow-up actions.

What Are SOAP Notes Used For?

SOAP notes are used to document patient encounters in a clear, structured way. They help healthcare professionals track patient progress, communicate with other providers, and make informed clinical decisions.

These notes are often required for insurance billing, as they support medical necessity and CPT coding. They’re also used during audits and chart reviews to verify quality of care.

Most importantly, SOAP notes serve as a legal record of the care provided. If there are mistakes in your notes, it can lead to rejected insurance claims.

Why Are SOAP Notes Important?

SOAP notes help keep your documentation organized, consistent, and compliant. They’re especially important for supporting care decisions, communicating with other clinicians, and meeting insurance and legal standards.

Here are some key reasons why SOAP notes are important for clinical documentation:

• They support medical necessity - Detailed documentation helps justify treatments and billing.

• They help improve care continuity - Notes make it easier for other providers to follow your plan and track progress.

• They save time during follow-ups - A clear record of previous visits cuts down on repetition and confusion.

• They protect against liability - Accurate, timely notes provide a legal record if your decisions are ever questioned.

• They help you meet compliance standards - Well-written SOAP notes reduce the risk of issues during chart reviews.

Keeping SOAP notes accurate and thorough not only helps your patients—it also protects your practice.

How to Write a SOAP Note

A SOAP note is divided into four sections that each serve a specific purpose. Knowing what to include in each part makes your documentation clearer, faster, and more effective.

Here's how to write a SOAP note:

What Goes in the Subjective of a SOAP Note?

The subjective section includes information the patient shares about their experience. This part captures their symptoms, medical history, and anything else they report that helps guide your assessment.

The subjective section should reflect the patient's voice and focus on relevant concerns. Here's what it should include:

• Chief complaint that outlines the main issue or reason for the visit, often in the patient's own words

• History of present illness (HPI) that details about the symptom's onset, duration, severity, and triggers

• Past medical, family, and social history (PFSH) that is relevant background that could affect diagnosis or treatment

• Medications and allergies

• Patient-reported outcomes

What Goes in the Objective of a SOAP Note?

The objective section includes data that you observe or measure during the visit. This can come from physical exams, diagnostic tools, or reviewed lab results.

The objective section should focus on facts, not interpretations. Here's what it should include:

• Vital signs such as blood pressure, temperature, heart rate

• Physical exam findings from inspection, palpation, auscultation, etc.

• Test results including labs and imaging available during the visit

• Observations of behavior, posture, speech, or other physical cues

• Measurements like range of motion, wound size, or weight

What Goes in the Assessment of a SOAP Note?

The assessment section is where you interpret the information collected. It should include your clinical judgment, diagnoses, and reasoning based on the subjective and objective data.

In this section, remember to be concise but specific. Here's what it should include:

• Primary diagnosis that best explains the patient’s condition

• Differential diagnoses for other possibilities

• Clinical impression of how the patient’s condition is progressing

• Response to treatment, if the patient has been seen before

• ICD-10 codes to support billing and documentation

What Goes in the Plan of a SOAP Note?

The plan outlines your next steps and what the patient should do moving forward. It includes treatment, follow-up instructions, and any referrals or tests ordered.

In the plan section of your SOAP notes, be actionable and include specifics. Here's what they should include:

• Medications prescribed or changed, with instructions

• Referrals to specialists or support services

• Orders for labs, imaging, or procedures

• Patient education provided during the visit

• Follow-up plans and timelines

Best Free AI SOAP Note Generator

Writing SOAP notes after patient visits shouldn't take up all of your time. It's important to make sure they're accurate, but it's not possible to spend hours on each one making sure it's perfect.

Instead, use AI Blaze to generate SOAP notes with AI right in your EMR and reclaim your time so you can spend more time with patients, not paperwork.

AI Blaze is your personal AI assistant that helps you proofread and review your notes, generate notes in any format, summarize data, and much more.

AI Blaze works on any website or EMR and helps you streamline your documentation, no integration required.

Features

• Generate SOAP notes with AI - Quickly generate clinical notes with AI in any EMR.

• Polish/reformat your notes - AI Blaze can take your rough notes and quickly rewrite them to fit guidelines & requirements and help make sure they are compliant.

• Summarize notes & text on any website - Summarize your notes or any text (including images) using AI that works anywhere you do.

• AI Blaze works in any EMR (no integration required)! - Use AI Blaze to save time right where you work without the hassle of integration.

SOAP Note Examples & Templates

If you need a template to copy & customize or just want to see some examples of what a SOAP note actually looks like when filled out, check out the examples and templates below.

General SOAP Note Template

Use this general SOAP note template to quickly document visits or copy/paste into your notes and customize.

Mental Health SOAP Note Example

This template is useful for behavioral health or counseling visits. It includes patient-reported symptoms, clinician observations, and a clear treatment plan.

Physical Therapy SOAP Note Example

This example is tailored for documenting a follow-up visit in a rehab setting. It tracks progress and outlines next steps for therapy.

SLP SOAP Note Example

Use this for documenting a speech-language pathology session. It includes structured observations and a focused therapy plan.

Nursing SOAP Note Example

This note is designed for daily charting on a medical-surgical floor. It captures patient concerns, nursing assessments, and communication with the care team.

SOAP Notes FAQ

What Is the Format of a Soap Note for Medical Documentation?

The standard format of a SOAP note in medical documentation includes four sections: Subjective, Objective, Assessment, and Plan.

Each section should be clearly labeled and organized to match what payers and auditors look for.

Check out the section how to write a SOAP note above to learn exactly how to write a SOAP note and what to include in each section.

What Are the Requirements of SOAP Notes for Documentation?

To be compliant, SOAP notes must include specific elements that justify clinical decisions and meet payer, legal, and institutional standards. Missing or vague information can lead to denied claims or failed audits.

Here are key things your SOAP notes should include:

• Chief complaint and history - Document the patient’s main reason for the visit and detailed HPI using a structure like OLDCARTS.

• Objective data and findings - Record measurable data like vitals, physical exam results, and reviewed labs or imaging.

• Clinical reasoning and diagnosis - Clearly state your assessment, list differential diagnoses if applicable, and explain why you chose the primary one.

• Plan of care with follow-up - Include medications, tests ordered, referrals, and when the patient should return or be contacted.

• Medical necessity language - Show why the visit, treatment, or follow-up was needed based on symptoms and findings.

• ICD-10 and CPT code alignment - Make sure diagnoses and services match what’s documented in the note to avoid billing issues.

Including these details helps ensure your SOAP notes hold up for reimbursement, continuity of care, and legal documentation.

Write Compliant SOAP Notes in 2025

SOAP notes are still one of the most efficient ways to document clinical encounters. When written clearly and thoroughly, they support patient care, improve communication, and meet billing and legal requirements.

To recap, use AI Blaze to generate SOAP notes with AI and reclaim your time so you can spend more time with patients, not paperwork.