In an industry where we get a maximum of 7 minutes to write a SOAP note, we understand how overwhelming it must be to start writing your first SOAP note.

Whether you are a student or a practitioner seeking better ways to write SOAP notes, you are in the right place.

In this article, you’ll learn:

• What is a SOAP note (with examples)
• How to write a SOAP note
• Avoid common SOAP note mistakes
• Real-world SOAP note template that you can use
• 20+ Real world SOAP note examples

What is a SOAP Note?

SOAP note is a documentation method to capture detailed patient information. SOAP note is an acronym for Subjective, Objective, Assessment, and Plan (explained in depth in the next section).

SOAP notes are a very quick and easy way to record your patient’s progress or simply log necessary information that would be otherwise very hard to capture if left to subjectivity.

What makes SOAP notes indispensable to the medical industry is that they serve as a framework to:

• Capture subjective information
• Capture objective information
• Helps shape an assessment plan based on subjective and objective information available.
• Finally, create a plan that both a medical practitioner and a patient can agree upon and track

The simplicity of using SOAP notes makes it easy to capture a broad set of information and communication that would otherwise be too hard to capture.

Before we show you a SOAP note example, let’s first understand the SOAP acronym.

What Does SOAP Note Acronym Stand For?

SOAP Acronym stands for Subjective, Objective, Assessment, and Plan.

These four independently capture and track different types of information. Let’s take a look at each of those four in a bit more detail now.

Subjective: Patient’s own account of the symptoms they are experiencing and their perception of the progress of current treatment. “What a patient tells you” is the best way to describe the subjective part of a SOAP note.

Patient-reported information about when the symptoms first appeared, the location of the symptom, pain experienced as a result of the problem, etc.

Objective: As a medical practitioner, the objective part is where you collect factual information to support assessment.

Generally, we collect FamHx, PmHx, existing treatments that the patient is undergoing, age, gender, etc when it comes to the objective part of the SOAP note.

Assessment: When subjective and objective information is collected, we synthesize both into an assessment. This part of your SOAP note is the interpretation of subjective and objective data at hand. Add the problem and the potential diagnosis here.

Plan: In the “plan” part of your SOAP note, add the next steps for the patient’s treatment - e.g. tests, consults, etc.

How to Write a SOAP Note

While writing a SOAP note follow these guidelines:

• Create 2-4 sections to accommodate subjective, objective, assessment, and plan within your SOAP note. You can create a separate section for subjective and objective information while keeping a single section for assessment and plan.
• Avoid writing verbose SOAP notes. Stick to short, helpful notes.
• When it comes to writing the subjective section of the SOAP note, try to use a set of exploratory questions that can help you better leverage objective information. It is often helpful to lead with both open-ended discovery questions and close-ended in-depth questions.
• If you are a beginner, go over your SOAP note once you are done and remove information that’s unnecessary. Repeat this process for a few weeks and you’ll see that your SOAP notes would improve.

What do You Write in a SOAP Note?

In a typical SOAP note, you add the following information under each section:

• Subjective: Collect the patient’s own account of when the symptom started, what symptoms appeared, what they experienced, etc. Be as concise as you can while writing this part. Use a set of guiding questions to gather relevant information.
• Objective: Collect the patient’s objective data here including - age, gender, vital signs, lab results, etc.
• Assessment: List the patient’s complaints in the order of importance, with the primary complaint at the top. While listing complaints, write your assessment near them as well.
• Plan: While writing your SOAP note’s plan section - clearly list the next steps, referrals for consults, tests to be performed, prescriptions, next appointment date, etc.

The Best Way to Understand a SOAP Note

To understand a SOAP note, divide the SOAP note into subjective, objective, assessment, and plan information. Separate subjective and objective information to see if assessment and plan are appropriate.

SOAP notes generally change based on the type of practice you run, and we will list 20+ examples at the end of this post. A generic SOAP note template has been placed in the next section for you.

SOAP Note Template

Subjective: {Patient’s first name} reported experiencing {symptom}, {pain}, etc on {date} starting at {time}.

Objective: {Patient’s first name} has {condition e.g. low blood pressure}.

Patient did:

1. {step 1}
2. {step 2}
3. {step 3}

The patient’s condition is {condition 1}, {condition 2}, and {condition 3}.

PmHx: {Add patient’s medical history here}

FamHx: {Add patient’s family medical history here}

Patient’s current prescription as of {date}:

1. {prescription 1}: {dose} - taken at {frequency}
2. {prescription 2}: {dose} - taken at {frequency}
3. {prescription 3}: {dose} - taken at {frequency}

Assessment: {Patient’s first name}’s {vital/test information}:

1. {information 1}
2. {information 2}
3. {information 3}

{Patient’s first name} is here for {reason e.g. follow-up} and is suffering from {condition}.

Plan: {Patient’s first name} should {do something e.g. exercise and avoid eating fat}.

Discussed {plan of action} and {Patient’s first name} agreed to follow it.

Follow-up is scheduled for {date}. Assess {vitals e.g. THC count}. Consider {next steps} if {condition} doesn’t improve.

11 SOAP Note Subjective Question Examples

1. How’s {condition} since {date}?
2. When did your primary symptoms first appear?
3. How would you describe {symptoms}?
4. How are you feeling today?
5. Have you got any {symptoms} related to {condition} today?
6. How have you been since the last time we spoke at {date}?
7. Where {is/are} the {symptoms} located?
8. What makes {condition} better?
9. What makes {condition} worse?
10. Is {condition} localized?
11. On a scale of 1 to 10 (with 10 being the highest) how would you rate the {condition}?

7 SOAP Note Examples

In this section, you’ll find easy-to-use and customizable SOAP notes for a range of practices. You can find the following 7 SOAP note examples below:

1. Chiropractic SOAP notes
2. Physical therapy SOAP notes
3. Massage therapy SOAP notes
4. 2 SOAP notes for cancelled session
5. Mental health SOAP note

SOAP Note Example for Chiropractors

{Patient’s full name}

Subjective: {Add subjective information here}

Objective: Range of motion: {Add information here} Orthopedic tests: {Add information here} Neurological tests: {Add information here} Imaging studies: {Add information here}

Adjustments provided:

L: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

R: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

BL: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Ant: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Post: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Hypomobile: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Hypertonic: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Tender: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Inflamed: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Adjusted: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Mobilized: {Occiupt/ C1/ C2/ C3/ C4/ C5/ C6/ C7/ T1/ T2/ T3/ T4/ T5/ T6/ T7/ T8/ T9/ T10/ T11/ T12/ L1/ L2/ L3/ L4/ L5/ Scaral Apex/Coccyx/AC jt/SC jt/ Ulnar head/ Radial head/ Lunate/ Fibular head/ Talus}

Modalities: {cryotherapy/ electric muscular stimulation/ moist heat/ ultrasound}

{Add additional bjective information here}

Assessment: {Add assessment information here}

Plan: Goal(s): {Add information here} Return: {Add information here} Frequency of visits: {Add information here}

SOAP Note Example for Physical Therapy

Subjective: PmHx: {Add patient’s medical history here}

FamHx: {Add patient’s family medical history here}

Patient is experiencing {condition} from {date}

{Pain/ Stiffness/ Numbness/ Tingling} serverity reported by the patient: {1/ 2/ 3/ 4/ 5/ 6/ 7/ 8/ 9/ 10}

{Condition 1}: Patient is feeling {same/better/worse} {Condition 2}: Patient is feeling {same/better/worse} {Condition 3}: Patient is feeling {same/better/worse} {Condition 4}: Patient is feeling {same/better/worse}

{Add any other subjective information here}

Objective and Assessment: WNL: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

Same: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

Increased: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

Decreased: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

By 5 degr: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

By 10 degr: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

By 15 degr: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

By 20 degr: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

By 25 degr: {Cerv Flexion (50)/ Cerv Extension (60)/ Cerv Lateral bending L (45)/ Cerv Lateral bending R (45)/ Cerv Rot L (80)/ Cerv Rot R (80)/ Lumbosacral Flexion (60)/ Lumbosacral Extension (25)/ Lubosacral Lateral bending L (25)/ Lumbosacral Lateral bending R (25)/ L Shoulder Flexion (180)/ L Shoulder Extension (50)/ L Shoulder Abduction (150)/ L Shoulder Internal Rot (90)/ L Shoulder External Rot (90)/ R Shoulder Flexion (180)/ R Shoulder Extension (50)/ R Shoulder Abduction (150)/ R Shoulder Internal Rot (90)/ R Shoulder External Rot (90)/ L Hip Flexion (125)/ L Hip Extension (15)/ L Hip Abduction (45)/ L Hip Adduction (30)/ L Hip Internal Rot (40)/ L Hip External Rot (45)/ R Hip Flexion (125)/ R Hip Extension (15)/ R Hip Abduction (45)/ R Hip Internal Rot (40)/ R Hip External Rot (45)/ L Knee Flexion (130)/ L Knee Extension (0)/ R Knee Flexion (130)/ R Knee Extension (0)}

Orthopedic tests: {Add information here}

Treatment performed: {Add information here}

Modalities used: {conditition 1}: {Manual therapy/ Hot or Cold/ Therapeutic Exercises/ Ultrasound/ Laser/ Traction/ EMS/ Other} for {5 minutes/ 10 minutes/ 15 minutes/ 30 minutes} {conditition 2}: {Manual therapy/ Hot or Cold/ Therapeutic Exercises/ Ultrasound/ Laser/ Traction/ EMS/ Other} for {5 minutes/ 10 minutes/ 15 minutes/ 30 minutes} {conditition 3}: {Manual therapy/ Hot or Cold/ Therapeutic Exercises/ Ultrasound/ Laser/ Traction/ EMS/ Other} for {5 minutes/ 10 minutes/ 15 minutes/ 30 minutes}

Modality notes: {Add modality notes here}

Treatment was {well tolerated/ tolerated without incident/ was tolerated with mild reactions/ other}

Reaction notes: {Add reaction information here/ No reactions}

Plan: Continue plan: {yes/ move to new plan}

Goals: Pain reduced to {0/10, 2/10, 4/10} in {4 weeks/ 6 weeks/ 8 weeks/ 12 weeks}

Other goals: {Add other goals/none}

Visits: {once per week/thrice per week}for {4 weeks/ 6 weeks/ 12 weeks}

Additional plan notes: {Add additional plan notes here/none}

SOAP Note Example for Message Therapy

{Patient’s full name}

Session type: {Swedish/ Hot Stone/ Aromatherapy/ Deep Tissue/ Sports/ Trigger Point/ Reflexology/ Shaitsu/ Prenatal/ Couple’s/ Chair/ Other}

Duration: {15 minutes/ 30 minutes/ 45 minutes/ 60 minutes/ 75 minutes/ 90 minutes/ 120 minutes/}

Symptoms:

Head: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Neck: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Shoulder : {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Upper Arm : {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Forearm: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Hand: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Upper Back: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Midback: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Lower Back: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Chest: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Upper Abdomen: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Lower Abdomen: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Buttock: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Upper Thigh: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Lower Thigh: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Knees: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Upper Leg: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Ankle: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation} Foot: {L /R/ BL/ Ant/ Post/ Adhesion/ Rotation}, {Pain/ Tender Point/ Hypertonicity /Spasm/ Inflammation / Trigger Point /Elevation}

Objective: Clinical observations: {Add your clinical observations here}

Current medications: {Add notes on client’s current medications}

Assessment: Treatment: {Add notes on treatments prescribed or followed} Client’s response: {Add notes on client’s response to the treatment}

Plan: Treatment options:

• {Treatment option 1}
• {Treatment option 2}
• {Treatment option 3}

Referral: {Add referral here/ none}

Self-care recommendations:

• {Self-care recommendation 1}
• {Self-care recommendation 2}
• {Self-care recommendation 3}
• {Self-care recommendation 4}

SOAP Note Example for Cancelled Session

“No data obtained - {date}session cancelled”

SOAP Note Example for Session Cancelled by Clinician

“N/A - Clinician cancelled”

SOAP Note Example for Mental Health

{Patient’s full name}

Patient’s characteristics:

• Appearance: {well groomed/ unkempt/ inappropriate attire/ poor hygiene/other}
• Speech: {normal/ pressured/ poverty of/ impaired/ slow/ rapid/ monostone/ other}
• Mood: {congruent/ flat/ depressed/ manic/ anxious/ fearful/ irritable/ angry/ liable/ incongruent/ other}
• Behavior: {normal/ cooperative/ guarded/ withdrawn/ defensive/ oppositional/ hostile/ manipulative/ impaired/ threatening/ impulsive/ tearful/ tearful/ tired/ other}
• Thought content: {WNL/ suicidal ideation/ loose association/ paranoid/ obsessive/ psychotic/ other}

Current prescription: {add information on client’s current prescription}

Current treatment goals: {add current treatment goals here}

Subjective: {add subjective notes here}

Objective: {add objective notes here}

Assessment: {add assessment notes here}

Plan:

Is {Patient’s first name} a danger to self or others: {Yes/ No}

{Add other plan notes here}

Next visit scheduled for {date}

Services rendered on {current date}: {initial evaluation/ 30 min - psychotherapy/ 60 min - psychotherapy/ family w/ patient - psychotherapy/ family w/o patient - psychotherapy/ multi-family psychotherapy/ group - psychotherapy/ crisis - 30-60 min psychotherapy/ crisis - additional 30 min - psychotherapy/ other}

Read more:

• Dermatology SOAP Note Examples