15 SOAP Note Examples in 2024

By Jamie Frew on Aug 13, 2024.

Fact Checked by Nate Lacson.

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Introduction

SOAP notes are a widely used and accepted format by healthcare practitioners, from mental health professionals to physicians and social workers, to capture client information in an easy-to-understand way. Using a SOAP note format, clinicians can ensure they extract valuable information from patients in both a subjective and objective manner. Using the information gathered, healthcare professionals can then assess the patient for a viable and effective treatment plan in response to their clinical diagnosis.

You probably already know this, but SOAP is an acronym that stands for subjective, objective, assessment, and plan. Each letter refers to the different components of a soap note and helps outline the information you need to include and where to put it.

Even though SOAP notes are a simple way to record your progress notes, having an example or template is still helpful. That's why we've taken the time to collate some SOAP note examples. They can be useful in helping you write more detailed and concise notes from the subjective and objective data to the planning part.

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How to write a SOAP note

Although every practitioner will have their preferred methods for writing SOAP notes, there are helpful ways to ensure you cover all the correct information. We've already covered the type of information that should be covered in each section of a SOAP note, but here are some additional ways to guarantee this is done well. 

Subjective

The subjective section covers how the patient feels and what they report about their symptoms. The main topic, symptom, or issue that the patient describes is known as the chief complaint (CC). There may be more than one CC, and the primary CC may not be what the patient initially reports on. As their physician, you need to ask them as many questions as possible so you can identify the appropriate CC. 

A history of present illness (HPI) also belongs in this section. This includes questions like:

  • When did the symptoms begin?
  • When did you first notice the CC?
  • Where is the CC located?
  • What makes the CC better?
  • What makes the CC worse?

Pro tip #1: It is a good idea to include direct quotes from the patient in this section. 

Pro tip #2: Writing the subjective section needs to be concise. This may mean compacting the information the patient has given you to get the information across succinctly. 

Objective

The objective section includes the data that you have obtained during the session. This may include:

  • Vital signs
  • Laboratory results
  • X-ray results
  • Physical exam

Based on the subjective information that the patient has given you and the nature of their CC, you will respond appropriately and obtain objective data that indicates the signs of the CC. 

In addition to gathering test/lab results and vital signs, the objective section will include your observations about how the patient presents. This has their behavior, effect, engagement, conversational skills, and orientation. 

Pro tip #3: Confusion between symptoms and signs is common. The patient's symptoms should be included in the subjective section. In contrast, signs refer to quantifiable measurements or objective observations you have gathered indicating the presence of the CC.

Assessment

It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan. 

If there are several different CCs, you may want to list them as ‘problems,' as well as the responding assessments. Practitioners frequently use the assessment section to compare their patients' progress between sessions, so you want to ensure this information is as comprehensive as possible while remaining concise. 

Pro tip #4: Although the assessment plan synthesizes information you've already gathered, you should never repeat yourself. Don't just copy what you've written in the subjective and objective sections. 

Plan

The final section of a SOAP note covers the patient's treatment plan in detail based on the assessment section. You want to include immediate goals, the date of the next session (where applicable), and what the patient wants to achieve between their appointments. 

In future sessions, you can use the plan to assess the patient's progress and determine whether the treatment plan needs to be changed. 

The plan section may also include:

  • Referrals to specialists
  • Patient education
  • Medications
  • If further testing is required
  • Progression or regression made by the client

How to write a SOAP note

Although every practitioner will have their preferred methods for writing SOAP notes, there are helpful ways to ensure you cover all the correct information. We've already covered the type of information that should be covered in each section of a SOAP note, but here are some additional ways to guarantee this is done well. 

Subjective

The subjective section covers how the patient feels and what they report about their symptoms. The main topic, symptom, or issue that the patient describes is known as the Chief Complaint (CC). There may be more than one CC, and the primary CC may not be what the patient initially reports on. As their physician, you need to ask them as many questions as possible so you can identify the appropriate CC. 

A History of Present Illness (HPI) also belongs in this section. This includes questions like:

  • When did the symptoms begin?
  • When did you first notice the CC?
  • Where is the CC located?
  • What makes the CC better?
  • What makes the CC worse?

Pro tip #1: It is a good idea to include direct quotes from the patient in this section. 

Pro tip #2: Writing the subjective section needs to be concise. This may mean compacting the information the patient has given you to get the information across succinctly. 

Objective

The objective section includes the data that you have obtained during the session. This may include:

  • Vital signs
  • Laboratory results
  • X-ray results
  • Physical exam

Based on the subjective information that the patient has given you and the nature of their CC, you will respond appropriately and obtain objective data that indicates the signs of the CC. 

In addition to gathering test/lab results and vital signs, the objective section will include your observations about how the patient presents. This has their behavior, effect, engagement, conversational skills, and orientation. 

Pro tip #3: Confusion between symptoms and signs is common. The patient's symptoms should be included in the subjective section. In contrast, signs refer to quantifiable measurements or objective observations you have gathered indicating the presence of the CC.

Assessment

It can help to think of the assessment section of a SOAP note as the synthesis between the subjective and objective information you have gathered. Using your knowledge of the patient's symptoms and the signs you have identified will lead to a diagnosis or informed treatment plan. 

If there are several different CCs, you may want to list them as ‘Problems,' as well as the responding assessments. Practitioners frequently use the assessment section to compare their patients' progress between sessions, so you want to ensure this information is as comprehensive as possible while remaining concise. 

Pro tip #4: Although the assessment plan synthesizes information you've already gathered, you should never repeat yourself. Don't just copy what you've written in the subjective and objective sections. 

Plan

The final section of a SOAP note covers the patient's treatment plan in detail based on the assessment section. You want to include immediate goals, the date of the next session (where applicable), and what the patient wants to achieve between their appointments. 

In future sessions, you can use the plan to identify the patient's progress and judge whether the treatment plan requires changing. 

The plan section may also include:

  • Referrals to specialists
  • Patient education
  • Medications
  • If further testing is required
  • Progression or regression made by the client

SOAP note examples and templates

Although the above sections help outline the requirements of each SOAP notes section, having an example in front of you can be beneficial. That's why we've taken the time to collate some examples and SOAP note templates, which we think will help you write more detailed and concise SOAP notes.

SOAP note example for nurses or nurse practitioners

Subjective

John reports feeling tired and struggling to get out of bed in the morning. He also struggles to get to work and constantly finds his mind wandering to negative thoughts. John stated that his sleep had been broken, and he did not wake feeling rested. He reports that he does not feel as though the medication is making any difference and thinks he is getting worse.

Objective

John could not come into the practice and has been seen at home. John's personal hygiene does not appear to be intact; he was unshaven and dressed in track pants and a hooded jumper, which is unusual as he typically takes excellent care of his appearance. John appears to be tired. He has a pale complexion and large circles under his eyes.

John's compliance with his new medication is good, and he appears to have retained his food intake. Weight is stable and unchanged.

Assessment

The client's symptoms are consistent with a major depressive episode. This is evidenced by his low mood, slowed speech rate and reduced volume, depressed body language, and facial expression. However, it's important to note that this assessment is based on the information presented, and a full diagnosis can only be confirmed by a qualified mental health professional.

Further exploration is needed to understand the duration and severity of these symptoms, as well as any potential contributing factors such as life stressors, relevant medical history, or personal and family history. Additionally, while suicidal ideation is currently denied, it is crucial to monitor for any changes and ensure appropriate safety measures are in place.

Plan

Diagnosis: Major depressive disorder, recurrent, severe (F33.1 ICD-10) - Active

Problem: Depressed mood

Rationale: John's depressed mood, evidenced by ongoing symptoms consistent with Major Depressive Disorder, significantly impacts his daily life and requires continued intervention.

Long-term goal: John will develop skills to recognize and manage his depression effectively.

Short-term goals and interventions:

  1. Maintain treatment engagement: Continue attending weekly individual therapy sessions to address negative thinking patterns, build coping mechanisms, and monitor progress.
  2. Optimize medication: Collaborate with the prescribing physician to continue titration of the SSRI fluoxetine as needed, ensuring optimal symptom control.
  3. Engage in daily physical activity: Encourage participation in structured physical activity, such as walking Jingo once a day, to improve mood and energy levels.
  4. Implement a safety plan: Develop a collaborative safety plan with John outlining clear steps and resources he can access in moments of suicidal ideation, ensuring his safety and well-being.

SOAP note example for psychotherapists

Subjective

Stacey reports that she is 'feeling good' and enjoying her time away. Stacey reports she has been compliant with her medication and uses her meditation app whenever she feels her anxiety.

Objective

Stacey was unable to attend her session as she is on a family holiday this week. She was able to touch base with me over the phone and was willing and able to make the phone call at the set time. Stacey appeared to be calm and positive over the phone.

Assessment

Stacey presented this afternoon with a relaxed mood. Her speech was normal in rate, tone, and volume. Stacey was able to articulate her thoughts and feelings coherently.

Stacey did not present with any signs of hallucinations or delusions. Insight and judgment are good. No sign of substance use was present.

Plan

Plan to meet again in person at 2 pm next Tuesday, 25th May. Stacey will continue on her current medication and has given her family copies of her safety plan should she need it.

Click here to access our SOAP Notes for Therapy Template.

SOAP note example for pediatricians

Subjective

Mrs. Jones states that Julia is "doing okay." Mrs. Jones said her daughter seems to be engaging with other children in her class. Mrs. Jones said Julia is still struggling to get to sleep and that "she may need to recommence the magnesium." Despite this, Mrs. Jones states she is "not too concerned about Julia's depressive symptomatology.

Objective

Mrs. Jones thinks Julia's condition has improved.

Assessment

Julia will require ongoing treatment.

Plan

Plan to meet with Julia and Mrs. Jones next week to review the treatment progress and adjust the plan as needed. Continue regular therapy sessions to support Julia's mental health and address any emerging concerns.

SOAP note example for social workers

Subjective

Martin reports experiencing a worsening of his depressive symptoms, describing them as "more frequent and more intense" compared to previous experiences. He feels the depressive state is constantly present, with no improvement in anhedonia and a significant decrease in energy levels compared to the previous month. He describes feeling constantly fatigued, both mentally and physically and reports difficulty concentrating and increased irritability.

Importantly, Martin also shared experiencing daily thoughts of suicide, although he denies having a specific plan or intention to act on them.

Objective

Martin denies any hallucinations, delusions, or other psychotic-related symptomatology. His compliance with medication is good. He appears to have gained better control over his impulsive behavior as they are being observed less frequently. Martin appears to have lost weight and reports a diminished interest in food and a decreased intake.

Assessment

Martin presents with significant symptoms consistent with major depressive disorder, including worsening mood, anhedonia, fatigue, difficulty concentrating, and daily thoughts of suicide. His verbal and cognitive functioning appears intact, with no signs of psychosis. He demonstrates some insight into his depression and denies any current plan or intent to act on his suicidal thoughts.

However, his nonverbal presentation paints a concerning picture, with listlessness, distractedness, slow physical movement, and depressed body language reflecting the severity of his depressive episode. It is crucial to monitor his safety closely and address the suicidal ideation with appropriate interventions despite the lack of an immediate plan.

Therefore, continuing therapy sessions with a focus on developing coping mechanisms, managing suicidal ideation, and exploring potential contributing factors is highly recommended.

Plan

Diagnosis: Major Depressive Disorder (MDD) - Active

Rationale: Martin's ongoing symptoms of depression, including daily suicidal ideation and significant functional impairment, necessitate continued intervention and support.

Short-term goals and interventions:

  1. Increase treatment frequency: Schedule a follow-up therapy session in two days, on Friday, May 20th, to provide immediate support and monitor safety.
  2. Reinforce safety plan: Review and reinforce Martin's existing safety plan, ensuring he understands and has accessible resources to address suicidal thoughts.
  3. Encourage communication with family: Discuss the importance of informing a trusted family member about his current state of mind and seeking their support while respecting Martin's autonomy concerning disclosure.

Additional considerations:

  • Potential for medication management: Explore the potential benefits and risks of medication management, such as anti-depressants, in consultation with a physician, considering the severity and duration of symptoms.
  • Collaboration with support systems: Consider involving other healthcare providers, such as Martin's primary care physician, in a coordinated care approach if deemed necessary.

SOAP note example for psychiatrists

Subjective

Ms. M. describes her current state as "doing okay," with a slight improvement in her depressive symptoms. While she still experiences persistent sadness, she acknowledges slight progress. Her sleep patterns remain disrupted, although she reports improved sleep quality and gets "4 hours sleep per night."

During the session, Ms. M. expressed discomfort with my note-taking, causing her anxiety. Additionally, she mentioned occasional shortness of breath and general anxiety related to healthcare providers. Interestingly, she expressed concern about the location of her medical records.

Objective

Ms. M. is alert. Her mood is unstable but improved slightly, and she is improving her ability to regulate her emotions.

Assessment

Ms. M. has a major depressive disorder.

Plan

Ms. M. will continue taking 20 milligrams of sertraline per day. If her symptoms do not improve in two weeks, the clinician will consider titrating the dose up to 40 mg. Ms. M. will continue outpatient counseling, patient education, and handouts. A comprehensive assessment and plan are to be completed by Ms. M's case manager.

The SOAP note could include data such as Ms. M's vital signs, the patient's chart, HPI, and lab work under the Objective section to monitor his medication's effects.

SOAP note example for therapists

Subjective

"I'm tired of being overlooked for promotions. I don't know how to make them see what I can do." Frasier's chief complaint is feeling "misunderstood" by her colleagues.

Objective

Frasier is seated, her posture rigid, and her eye contact is minimal. She appears to be presented with a differential diagnosis.

Assessment

Frasier is seeking practical ways of communicating her needs to her boss, asking for more responsibility, and how she could track her contributions.

Plan

Book a follow-up appointment. Work through some strategies to overcome communication difficulties and lack of insight. Request a physical examination from a GP or other appropriate healthcare professionals.

SOAP note example for counselors

Subjective

David states that he continues to experience cravings for heroin. He desperately wants to drop out of his methadone program and revert to what he was doing. David is motivated to stay sober by his daughter and states that he is "sober but still experiencing terrible withdrawals." He stated that [he] "dreams about heroin all the time and constantly wakes in the night drenched in sweat."

Objective

David arrived promptly for his appointment, completing his patient information sheet in the waiting room while exhibiting a pleasant demeanor during the session. He displayed no signs of intoxication.

While David still exhibits heightened arousal and some distractibility, his ability to focus has improved. This was evident during his sustained engagement in a fifteen-minute discussion about his partner and his capacity for self-reflection. Additionally, David demonstrated a marked improvement in personal hygiene and self-care. His recent physical exam also revealed a weight gain of 3 pounds.

Assessment

David demonstrates encouraging progress in his treatment journey. He actively utilizes coping mechanisms, ranging from control techniques to exercises, resulting in a decrease in his cravings, dropping from "constant" to "a few times an hour." This signifies his active engagement and positive response to treatment.

However, it is crucial to acknowledge that David still experiences regular cravings, indicative of his ongoing struggle. Coupled with his history of five years of heroin use, it underscores the need for further support. David would benefit from acquiring and implementing additional coping skills to consolidate his gains and progress toward sustainable recovery.

Therefore, considering both his current progress and the underlying factors related to his substance use, David would likely benefit from the addition of Cognitive Behavioral Therapy (CBT) alongside his current methadone treatment. Integrating CBT can equip him with valuable tools for managing triggers, challenging negative thoughts, and developing healthy coping mechanisms, ultimately enhancing his long-term recovery potential.

Plan

David has received a significant amount of psychoeducation within his therapy sessions. The therapist will begin to use dialectical behavioral therapy techniques to address David's emotional dysregulation. David also agreed to continue to hold family therapy sessions with his wife. Staff will continue to monitor David regularly in the interest of patient care and his past medical history.

SOAP note example for occupational therapists

Subjective

Ruby stated that she feels 'energized' and 'happy.' She states that getting out of bed in the morning is markedly easier, and she feels 'motivated to find work.' She has also stated that her 'eating and sleeping have improved' but that she is concerned she is 'overeating.'

Objective

Ruby attended her session and was dressed in a matching pink tracksuit. Her personal hygiene was good, and she had taken great care to apply her makeup and paint her nails. Ruby appeared fresh and lively. Her compliance with her medication is good, and she has been able to complete her jobseekers form.

Assessment

Ruby presented this morning with markedly improved affect and mood. Her speech was normal in rate and pitch and appeared to flow easily. Her thoughts were coherent, and her conversation was appropriate. Ruby's appearance and posture were different from those in our last session. Ruby's medication appears to be significantly assisting her mental health.

Plan

Short-term goals and interventions:

  1. Follow-up appointment: Schedule a follow-up session with Ruby in one week to monitor her progress and address any emerging concerns.
  2. Open communication: Encourage Ruby to maintain open communication with me and contact me for any assistance or questions regarding her job search process. This fosters a collaborative approach and ensures timely support.
  3. Medication adherence: Collaborate with Ruby to ensure continued adherence to her prescribed medication regimen, emphasizing its importance in managing her condition.
  4. Multidisciplinary team (MDT) review: Share this latest session's information with Dr. Smith for review within the MDT meeting. This facilitates collaborative analysis, discussion of potential diagnoses, and formulation of a comprehensive treatment plan.

Additional considerations:

  • Exploring potential vocational support: Depending on Ruby's needs and the MDT's recommendations, exploring additional vocational support services might prove beneficial. These could include career counseling, interview preparation workshops, or specialized job search resources tailored to her specific situation.
  • Addressing underlying factors: Further assessment is essential to identify any underlying factors contributing to Ruby's presentation, such as anxiety or depression, that might require additional interventions tailored to address them.

Click here to see our SOAP Notes For Occupational Therapy Template.

SOAP note example for dentists

Subjective

Chief complaint: A 56-year-old woman presents with a chief complaint of "painful upper right back jaw for the past week or so."

History of present illness: The client reports experiencing pain in her upper right back jaw for approximately one week. She describes the pain as [insert patient's description of the pain, e.g., sharp, dull, throbbing, aching]. She states that the pain is [insert patient's description of pain characteristics, e.g., constant, intermittent, worse with specific activities]. She denies any history of fever, chills, facial swelling, difficulty swallowing, or earache.

Past medical history: The patient denies any significant past medical history.

Medications: The patient denies taking any current medications.

Allergies: The patient reports an allergy to paracetamol.

Social history: The patient reports a history of [insert details of tobacco use, e.g., smoking cigarettes for 30 years, one pack per day] and [insert details of alcohol consumption, e.g., occasional social drinking].

Objective

Vitals:

  • Blood pressure: 133/91 mmHg
  • Heart rate: 87 beats per minute
  • Temperature: 98.7 °F (37.1 °C)

Clinical Examination:

Extraoral:

  • No signs of swelling, asymmetry, pain, redness (erythema), numbness (paraesthesia), or tenderness to palpation (TMI) were observed in the external facial and jaw areas.

Intraoral:

  • Tooth #17 (FDI #27) is supra-erupted and contacting (occluding) the pericoronal tissues (gum tissue surrounding the crown) of tooth #16.
  • Tooth #16 is partially erupted and exhibits:
    • Red, inflamed gum tissue (erythematous gingiva)
    • Presence of discharge (exudate)
    • Pain upon palpation

Radiology:

  • Pending - X-rays (including periapical (PA) and panoramic (Pano) views, or possibly a CT scan) are recommended to further evaluate the underlying anatomy and identify any potential bone involvement.

Assessment

  • Pericoronitis: The patient exhibits clinical signs consistent with pericoronitis affecting tooth #16. This includes the presence of:
    • Partial eruption of the tooth
    • Inflamed gum tissue (erythema)
    • Discharge (exudate) around the tooth
    • Pain upon palpation
    • Supra-eruption of the opposing tooth (#17) and its contact with the affected tissue
  • Contributing factors: While a definitive cause cannot be established without further investigation, the patient's smoking history (one pack per week) could potentially contribute to the development of pericoronitis by compromising the immune response and increasing the risk of infection.
  • Additional considerations: Further information is necessary to fully understand the underlying factors. Pending X-rays (PA and panoramic) will provide valuable insights into the bone structure and identify any potential complications, such as impaction or bone loss.

Therefore, a definitive diagnosis and comprehensive treatment plan will be determined following the completion of the X-ray studies and considering the patient's full medical history and any additional information gathered.

Plan

  • Pain management: OTC pain meds (consider allergy) & warm compresses (10-15 min, several times/day).
  • Definitive treatment: Schedule extraction of #17 after X-ray review.
  • Antibiotics (pending): Consider a 5-7 day course of amoxicillin based on X-ray and severity.
  • Follow-up: See patient in 3-5 days (healing, post-op concerns, oral hygiene).
  • Oral hygiene education: Instruct on proper brushing/flossing and gentle cleaning of affected area.
  • Smoking cessation: Encourage quitting to improve healing and reduce infection risk.

Click here to see our SOAP Notes for Dental Template.

SOAP note example for speech therapists

Subjective

Jenny's mother stated, "Jenny's teacher can understand her better now." Jenny's mother is "stoked with Jenny's progress" and can "see that the improvement is helpful for Jenny's confidence."

Objective

Jenny was able to produce /I/ in the final position of words with 80% accuracy.

Assessment

Jenny's pronunciation has improved by 20% since the last session with visual cues of tongue placement. Jenny has made marked improvements throughout the previous 3 sessions.

Plan

Jenny continues to improve with /I/ in the final position and is reaching the goal of /I/ in the initial position. Our next session will focus on discharge.

SOAP note example for physical therapists 

Subjective

At the time of the initial assessment, Bobby complained of dull aching in his upper back at a level of 3-4 on a scale of 10. Bobby stated that the "pain increases at the end of the day to a 6 or 7." Bobby confirmed that he uses heat at home and finds that a "heat pack helps a lot."

Objective

The cervical spine range of motion is within the functional limit, with pain to the upper thoracic with flexion and extension. Cervical spine strength is 4/5. The right lateral upper extremity range of motion is within the functional limit, and strength is 5/5. Palpation is positive over paraspinal muscles at the level of C6 through to T4, with the right side being less than the left. The sensation is within normal limits.

Assessment

Bobby is suffering from pain in the upper thoracic back.

Plan

To meet with Bobby on a weekly basis for modalities, including moist heat packs, ultrasound, and therapeutic exercises. The goal will be to decrease pain to a 0 and improve functionality.

SOAP note example for medical practitioners

Subjective

66-year-old Darleene presents for a follow-up appointment regarding her hypertension. She reports feeling well and denies any dizziness, headaches, or fatigue.

Medical history: Darleene has no significant past medical history beyond hypertension. Her current medication regimen consists solely of HCTZ 25mg daily.

Lifestyle: Over the past three months, Darleene has successfully lost 53 pounds by implementing a low-fat diet and incorporating daily 10-minute walks. Notably, she also acknowledges consuming two glasses of wine nightly. Darleene denies using any over-the-counter medications like cold remedies or herbal supplements.

Objective

Vital signs:

  • BP: 153/80 mmHg
  • Pulse: 76 beats per minute
  • Weight: 155 lbs
  • Height: 55 inches
  • BMI: ~30
  • General appearance: Well-nourished, no acute distress.
  • HEENT: Normocephalic, atraumatic, atraumatic, atraumatic (head, eyes, ears, nose, throat - all normal).
  • Neck: Supple, no jugular venous distention (JVD).
  • Lungs: Clear to auscultation bilaterally.
  • Heart: Regular rate and rhythm, no murmurs.
  • Abdomen: Soft, non-tender, no organomegaly.
  • Extremities: No edema.

Assessment

Darleene is here to follow up on her hypertension. It is not well-controlled since blood pressure exceeds the goal of 135/85. A possible trigger to her poor control of HTN may be her alcohol use or the presence of obesity.

Plan

1. Lifestyle modifications

  • Continue a low-fat diet and exercise: Encourage Darleene to maintain her current healthy diet.
  • Increase physical activity: To further support weight loss and overall health, I recommend gradually increasing walking duration to 20-30 minutes daily.
  • Moderate alcohol intake: Discuss the potential negative impact of excessive alcohol consumption on blood pressure control. Darleene agrees to limit her wine intake to weekend evenings only as a trial to assess its effect on her BP.

2. Monitoring and follow-up

  • Home blood pressure (BP) monitoring: Instruct Darleene to monitor her BP regularly at home and maintain a diary to document the readings.
  • Potassium level check: Schedule a blood test to assess her potassium level due to the potential electrolyte imbalance associated with diuretic use.
  • Follow-up appointment: Schedule a follow-up clinic visit in one month. At this visit, Darleene should bring her BP diary for review. Based on her progress, blood pressure readings, and overall evaluation, the addition of an ACE inhibitor medication might be considered if BP remains uncontrolled.

SOAP note example for massage therapists

Subjective

Fred stated that it had been about one month since his last treatment. Fred stated that he "has been spending a lot more time on his computer" and attributes the increased tension in his upper back and neck to this. Currently, Fred experiences a dull aching 4/10 in his left trapezius area. He "would like a relaxation massage focusing on my neck and shoulders."

Objective

Tenderness at the left superior angle of the scapula. Gross BUE and cervical strength. A full body massage was provided. TrPs at right upper traps and scapula. Provided client with education on posture when at the computer. Issued handouts and instructed on exercises. All treatment was kept within Pt.

Assessment

Fred reported 1/10 pain following treatment. Good understanding, return demonstration of stretches and exercises—no adverse reactions to treatment.

Plan

To continue DT and TRP work on the upper back and neck as required. Reassess posture and sitting at the next visit.

Click here to see our SOAP Notes for Massage Therapy Template.

Benefits of SOAP notes

SOAP notes immensely benefit professional health clinicians within the healthcare business space. Many online healthcare platforms, such as Carepatron, offer an integrated workplace to store SOAP note documentation. In addition to this, many platforms like Carepatron also offer SOAP templates from which to work to make this process easier. This is highly beneficial considering that SOAP notes are:

  • Easy to understand: Because of the SOAP formatting, they are easy for all healthcare professionals to read and are primarily used in healthcare facilities. 
  • Easy to interpret: Because of their professional approach, SOAP notes clearly outline the process from observation to the treatment plan.
  • Provide both subjective and objective perspectives: Allow the client to voice their experience, as well as use the scientific method to confirm what is seen.
  • Allows for compliance: As a documentation method, SOAP notes enable medical professionals to be held accountable for their healthcare practices, which avoids and reduces the misinterpretation and misconstruing of information. 

SOAP note downloadable templates

Now you know the benefits of using a SOAP note template, here are some downloadable options for you to choose from in terms of SOAP note writing:

  • SOAP Progress Notes Template: This SOAP Progress Notes Template separates the page into four relevant sections so you can lay out your information appropriately. 
  • SOAP Notes for Physical Therapy TemplatePerfect for physical therapists and massage therapists, this SOAP note template includes a body diagram so practitioners can be as specific as possible with their information.

Why go digital with SOAP Notes?

The healthcare landscape is changing, and technology offers clinicians exciting options. Software specifically designed for SOAP medical notes simplifies documentation, improves efficiency, and offers several key benefits:

  • Effortless templates: Access and customize pre-built SOAP templates to save time and ensure consistent formatting.
  • Secure storage: Ditch overflowing cabinets! SOAP note software offers secure, cloud-based storage solutions, keeping patient records readily accessible.
  • Streamlined compliance: Navigate HIPAA regulations with confidence. The right software handles data security and privacy protocols for you.
  • Time savings: Focus on what matters most—your patients. Streamline documentation and free up valuable time for patient care.

By adopting SOAP note software, you can modernize your practice, enhance efficiency, and ultimately, prioritize patient care.

Top 5 software solutions to write SOAP Notes

Many different software options are available for healthcare practitioners, and sometimes, it can be hard to know where to look. We've done some research and identified what we think to be the top 5 software solutions for writing SOAP notes. 

1. Carepatron

Carepatron is our number one when it comes to healthcare software. Integrated with extensive progress note templates, clinical documentation resources, and storage capabilities, Carepatron is your one-stop shop. 

The platform offers additional practice management software tools, including:

  • Appointment scheduling
  • Appointment reminders
  • Medical billing
  • Mobile app
  • Client portal
  • Dictation software

And most importantly, everything is HIPAA-compliant!

Carepatron has a free plan that is perfect for smaller businesses or start-up practices. If you want additional features, the professional plan is $12/month, and the organization plan is $19/month. 

2. TherapyNotes

TherapyNotes is a platform that offers healthcare practitioners documentation templates, including SOAP. The system integrates with a documentation library, allowing clinicians to store all their progress notes safely. Due to its practical progress note tools, TherapyNotes facilitates effective communication and coordination of care across a client's providers. 

Pricing:

  • Solo Plan: $49/month
  • Group Plan: $59/month for the first clinician and $30 per month per additional clinician

3. TheraNest

TheraNest's software gives clinicians unlimited group and individual therapy note templates. These notes are customizable and integrated with helpful tools like drop-down bars and DSM 5 codes.

Pricing:

  • Up to 30 clients: $42/month
  • Up to 40 clients: $54/month
  • Up to 50 clients: $65/month
  • Up to 80 clients: $98/month

4. Tebra

Tebra is a widespread practice management software integrated with SOAP note templates. It allows clinicians to streamline documentation with valuable features, including autosave and drop-down options. If you are interested in pricing, you should contact Tebra directly. 

5. SimplePractice

SimplePractice is our final recommendation for documentation software. It offers a comprehensive selection of fully customizable note templates. Integrated with Wiley Treatment Planners, the platform allows you to choose from a wide range of pre-written treatment goals, objectives, and interventions. 

Pricing:

  • Starter plan: $29/month
  • Essential plan: $69/month
  • Plus plan: $99/month

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