What Are SOAP Notes? The Complete Guide for Every Discipline
A SOAP note is a structured method of documenting a clinical encounter in four
parts: Subjective, Objective, Assessment and Plan. It records what the patient
reported, what the clinician observed or measured, what the clinician concluded, and what
happens next. It is used across medicine, nursing, physical and occupational therapy,
speech-language pathology, mental health and veterinary practice.
That is the definition. What follows is where the format came from, what actually belongs
in each section, how each discipline bends it to fit, and — the part most guides skip
— what the format is known to be bad at.
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Free · no email required Printable progress note templates Printable templates for the formats described above. Two free packs — blank and guided SOAP, DAP and BIRP progress notes, plus intake, treatment plan and discharge summary templates. |
Where SOAP notes came from
The format was developed by Dr. Lawrence Weed roughly fifty years ago as a component of
the problem-oriented medical record. Weed’s argument was that the medical record of the
time was organized by source — the lab’s results here, the nurse’s notes
there — and that this made a patient’s actual problems almost impossible to
follow. Organising the record by problem, and each problem by SOAP, made clinical reasoning
visible.
That is why the format spread so far beyond medicine. As the
StatPearls reference on SOAP notes
puts it, the structure functions as a cognitive framework for clinical reasoning, not merely
a filing convention. It reminds the clinician of specific tasks while providing a framework
for evaluating information — which is useful in any discipline that assesses,
concludes and acts.
The four sections
S — Subjective
What the patient, client or caregiver reports. Symptoms, history, concerns, and their account of what has changed. This is information you could not have obtained by observation alone.
O — Objective
What you observed, examined or measured. Vital signs, test results, physical findings, behavioral observations, scores. Reproducible information — another competent clinician examining the same patient should record substantially the same thing.
A — Assessment
Your professional interpretation. What the subjective and objective information means taken together: the diagnosis or differential, the progress, the clinical reasoning. This is the section that makes the record a clinical document rather than a log.
P — Plan
What happens next. Further investigation, treatment, referrals, education, and when you will review. Specific enough that another clinician could act on it.
The order is not arbitrary. What the patient reports shapes what you examine; together
those produce your judgment; your judgment produces the plan. A note where the Plan
does not follow from the Assessment is a note where something has gone wrong in the thinking,
not just the writing.
The distinction that causes the most trouble
this as a common error explicitly: a symptom is the patient’s own description, while a
sign is an objective finding related to it. A patient saying they have “stomach
pain” is a symptom and belongs in S. “Abdominal tenderness to palpation” is
a sign and belongs in O. The two questions that resolve almost every ambiguous line: could a
competent observer have seen or measured this, and would two clinicians describe it the same
way?
This single distinction accounts for more documentation review findings than any other
issue in the format, across every discipline that uses it.
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How each discipline adapts SOAP
The skeleton is constant; the content of each section shifts substantially. The original
format assumes vital signs and physical examination, and every discipline without those has
had to solve the Objective section in its own way.
Medicine
The original context. Subjective carries the chief complaint and history of present illness, often organized with a mnemonic such as OLDCARTS. Objective carries vital signs, physical examination findings, labs and imaging. Assessment is the differential diagnosis with the reasoning behind the ranking. Plan is investigation, treatment, referral and patient education, set out problem by problem.
Nursing
Frequently extended rather than used plain. SOAPIE adds Intervention and Evaluation — what was done and whether it achieved the intended outcome. SOAPIER adds Revision, for when the outcome falls short and the plan changes. Both exist because nursing documentation has to show a care cycle rather than a single decision point.
Physical therapy
Objective is the heaviest section: range of motion in degrees, manual muscle testing grades, gait observations, functional outcome measures. The Assessment carries an unusually specific burden — it has to establish why the treatment required the skills of a therapist rather than a competent assistant or a home programme, because that is what payers examine.
Occupational therapy
Organized around occupational performance rather than impairment. Objective records performance on activities of daily living and instrumental activities, with the level of assistance specified. Assessment links the impairment to the functional limitation, which is the connection that justifies the intervention.
Speech-language pathology
Objective is typically quantitative to a degree unusual elsewhere: accuracy percentages across trials, the cueing hierarchy level required, number of productions. Assessment interprets the trend across sessions rather than the single session, since progress in this field is often visible only in the slope.
Mental health and counseling
The hardest adaptation, because there are no vital signs. Objective becomes mental status observations — appearance, speech, affect, orientation — plus administered measures such as the PHQ-9 or GAD-7, and the interventions delivered. Assessment carries almost the entire weight of the note.
Veterinary medicine
The one context where the patient cannot contribute to the Subjective section at all. S becomes the owner’s report — appetite, behavior, elimination, what changed and when. This makes the subjective/objective distinction unusually clean, and it is why veterinary SOAP notes are often used as teaching examples.
If you work in mental health specifically, the counseling-focused version of this guide
— including a full worked example and the HIPAA distinction between progress notes and
psychotherapy notes — is at
what are SOAP notes in counseling.
What the format is bad at
Two limitations are well documented and worth knowing before you commit to SOAP as your
default.
It has no time dimension. A SOAP note captures a moment. Clinical
situations evolve, evidence accumulates, and diagnoses get revised — and the format
does not explicitly build that in. Extensions exist for exactly this reason: SOAPE adds an
Evaluation step as a prompt to assess how well the plan actually worked, and the nursing
variants SOAPIE and SOAPIER go further by separating out the intervention and, in SOAPIER,
the revision to the plan when the outcome falls short.
The reading order is not the most useful order. A clinician picking up a
colleague’s chart usually wants the Assessment and Plan first — what is going on
and what are we doing — not the history they already know. This is why some systems use
APSO, the same content reordered as Assessment, Plan, Subjective, Objective.
StatPearls cites a study finding APSO better than conventional SOAP order for speed, task
success and usability when physicians were retrieving information for a routine chronic
disease visit. Reordering is a presentation change; it does not alter the reasoning
relationship between the sections.
SOAP and the alternatives
SOAP is not the only structured format, and in some settings it is not the best one.
DAP merges Subjective and Objective into a single Data section —
faster, at the cost of the distinction above. BIRP reorganises around
Behavior, Intervention, Response and Plan, foregrounding what the clinician did and how the
patient responded, which suits settings where demonstrating the intervention is the priority.
Our comparison writes the same session in all three formats so the
trade-offs are visible rather than described.
Frequently asked questions
What does SOAP stand for?
Subjective, Objective, Assessment, Plan. Subjective is the patient’s report,
Objective is what was observed or measured, Assessment is the clinician’s
interpretation, and Plan is what happens next.
Who uses SOAP notes?
Physicians, nurses, nurse practitioners, physician assistants, physical and occupational
therapists, speech-language pathologists, athletic trainers, chiropractors, dietitians,
counselors, psychologists, social workers and veterinarians. Any discipline that assesses a
patient, forms a judgment and acts on it can use the structure.
Are SOAP notes a legal requirement?
No. What is generally required is that you document adequately, that the record supports
the necessity of what you did, and that it meets your regulator’s and payer’s
standards. SOAP is popular because it produces those elements reliably, not because any rule
mandates it. Requirements vary by jurisdiction, profession, employer and payer — check
yours.
What is the difference between a SOAP note and a progress note?
A progress note is the category; SOAP is one format for writing one. DAP and BIRP notes
are also progress notes. The terms are often used interchangeably, which causes confusion but
rarely any practical harm.
How long should a SOAP note take to write?
For a routine outpatient encounter, six to ten minutes once the format is habitual.
Intake and complex encounters take longer. If yours consistently run much longer, the
bottleneck is usually the Assessment section.
What is SOAPIE?
A nursing extension of SOAP that adds Intervention and Evaluation —
what was done, and whether it produced the intended outcome. SOAPIER adds Revision for
when it did not and the plan changes as a result.
Where can I see complete examples?
We have ten complete SOAP note examples written out in full, varying by
presenting problem and stage of treatment, and free
printable blank and guided templates.
Where to go next
If you are documenting in mental health, the
complete guide to SOAP notes for therapists covers the format in depth with
three worked notes. If you want to see finished notes rather than read about them, start with
the ten examples. If you want something to print and write on,
the free template pack has blank and guided pages for all three common
formats.
This article is general professional information for licensed clinicians and students, not legal, clinical or compliance advice. Documentation requirements vary by state, licensing board, payer and setting. Any example notes are composites written for illustration and do not describe real clients.
