Veterinary SOAP Note & Physical Exam Templates

What each part of a veterinary SOAP note holds:

• Subjective: the reason for the visit and the history in the owner's account. How long it has been going on, appetite, water intake, urination, defecation, vomiting, coughing, diet and preventatives.
• Objective: temperature, pulse, respiration, weight and body condition score, then the physical exam system by system. On a healthy patient most of those lines read the same every time.
• Assessment: the problem list, most significant first, and the differentials for the main problem.
• Plan: diagnostics, treatment with dose, route, frequency and duration, vaccines given, what the owner was told and chose, and the recheck.

Owners who ask for the SOAP notes vet clinics keep are asking for these records. The format is also how referral clinics, relief vets and the next doctor on shift read a case quickly, which is why it pays to write it the same way every time. The SOAP notes veterinary teams write still differ from clinic to clinic, so every line in this pack is plain text you can edit once and keep.

• Normals you edit down. The exam arrives as your clinic's normal findings. You change the lines that are abnormal today and leave the rest, so a full exam never takes a full exam's typing.
• Fields for what changes. Vitals, body condition score, problem list, differentials and treatment are form fields, so each record says what happened with this patient.
• Math done for you, checked by you. Type the weight in pounds and the kilograms appear. Pick the recheck interval and the date appears. Check both before you dose or book.
• Guidance that stays out of the record. A short reminder to keep what the owner said, what you found and what you conclude apart shows while you write and is never inserted.
• Text you can still edit. The record lands as ordinary text in whatever field you are in, so you can change anything before you save it. A default you leave alone lands as it is (the Diagnostics line starts as CBC, chemistry, urinalysis), and a bracketed prompt you leave empty lands in brackets, so read the record once before you save it.

If your PIMS templates work for you, keep them. Built-in templates are often excellent. This pack adds the same record in every other place you type, and the exam lines you can drop into any template, your PIMS's included.

If you use an AI scribe, the two work together. The scribe drafts from the exam-room conversation. The one-line snippets are the sentences you still type yourself when you review and complete the record: the BAR line, the normal heart and lungs, the plan closer.

Inside the pop-up

Patient, species and breed, age and sex, owner, date and doctor sit in a small table at the top, with your name saved once. S is a paragraph field for the history. O has fields for temperature, pulse, respiration and weight in pounds, with the kilograms computed beside it, and a BCS menu that names the band (thin, ideal, overweight or obese). Below the vitals is a short normal exam paragraph, one sentence per system group. For the full system-by-system exam, with hydration and urogenital lines, insert /pedog or /pecat in its place. A is a problem list field and a differentials line. P holds diagnostics, a checkbox that adds the vaccines you gave today from a menu, treatment, client communication and a recheck menu that writes the date for you.

Filled in for a fictional patient, the record reads:

Patient: Bella · Species / Breed: Canine, Labrador Retriever · Age / Sex: 7 y FS
Owner: Alice Smith · Date: 2026-09-18 · Doctor: Morgan Lee, DVM
S: Owner reports three days of soft stool, no blood or mucus. Bella is otherwise well, eating and drinking normally. She got into the compost bin over the weekend.
O: T 101.8 °F · P 96 · R 28 · Wt 78 lb (35.4 kg) · BCS 8/9 (obese)
Bright, alert and responsive. Mucous membranes pink and moist, CRT under 2 seconds. Eyes clear and ears clean. Teeth and gingiva normal for age. Peripheral lymph nodes small, soft and symmetric. Regular rhythm, no murmur or arrhythmia, femoral pulses strong and synchronous. Lung sounds clear in all fields, normal rate and effort. Abdomen soft and non-painful, no masses or organomegaly. Ambulatory on all four limbs, no lameness. Haircoat full and clean. Mentation appropriate, gait and cranial nerves normal.
A: 1. Acute soft stool, most likely dietary after the compost. 2. Obese body condition at BCS 8 of 9.
Differentials: dietary indiscretion, intestinal parasites
P: Diagnostics: fecal flotation, CBC and chemistry. Treatment: bland diet for five days, then a gradual return to her normal food. Vaccines deferred until her stool is normal.
Recheck in 1 week (September 25, 2026) or sooner if signs worsen.
Morgan Lee, DVM

The header labels, the normal exam, the kilograms, the BCS band, the recheck date and the signature were already there. The rest is what happened with this patient.

The normal exam templates

• /pedog: a system-by-system normal canine physical exam, general through neurologic, one line per system so you can edit the abnormal ones.
• /pecat: the same exam worded for cats, with thyroid palpation, resorptive lesions and kidney size in their places.

One-line snippets for the sentences you type most

• /bar, the BAR line: bright, alert and responsive, hydration, MM and CRT.
• /hl, heart and lungs normal in one sentence.
• /abdn, abdomen normal on palpation.
• /eent, eyes, ears, gums and teeth, with a dental grade menu.
• /integ, skin, coat and lymph nodes.
• /neuron, the neuro exam normal.
• /hx, the history opener, with a field for how long.
• /bcoll, a blood collection note with a venipuncture site menu.
• /ddx, the assessment and differentials opener.
• /plan, the plan closer with a recheck menu.

/pedog types a 14-line normal exam, about 1,200 characters, from six keystrokes. Start with /bar. It turns a sentence you type for almost every patient into four keystrokes, and it works inside any template, your PIMS's included.