Clinical Documentation Resource
Free SOAP Note Template for Clinics & Private Practices
A complete, copy-ready SOAP note framework — Subjective, Objective, Assessment, Plan — with section-by-section guidance and real examples to help your practice document faster and stay audit-ready.
Subjective
What the patient tells you
- Chief complaint (CC) in the patient's own words
- History of present illness (HPI): onset, location, duration, character, aggravating/relieving factors, timing, severity
- Relevant medical, surgical, family, and social history
- Current medications and allergies
- Review of systems (ROS) pertinent to the complaint
Example
CC: “Lower back pain for 3 weeks.” 42-year-old patient reports dull, constant right-sided lumbar pain (6/10) that worsens with prolonged sitting and improves with walking. No radiation, numbness, or bowel/bladder changes. Takes ibuprofen 400 mg PRN.
Objective
What you observe and measure
- Vital signs: BP, HR, temperature, respiratory rate, SpO2
- Physical exam findings by system
- Laboratory and imaging results
- Screening tool scores (e.g., PHQ-9, GAD-7)
- Measurable functional findings (range of motion, gait, strength)
Example
Vitals: BP 122/78, HR 72, T 98.4°F. Lumbar exam: tenderness over right paraspinal muscles L3–L5, flexion limited to 60°, negative straight leg raise bilaterally, 5/5 strength in lower extremities, sensation intact.
Assessment
Your clinical judgment
- Primary diagnosis with ICD-10 code where applicable
- Differential diagnoses considered and ruled out
- Severity, acuity, and risk factors
- Progress compared to prior visits
- Prognosis and contributing factors
Example
Mechanical low back pain, right lumbar strain (M54.51, S39.012A). No red flags for fracture, radiculopathy, or cauda equina. Improving trend vs. prior visit; good prognosis with conservative management.
Plan
What happens next
- Treatments, procedures, and therapies ordered
- Medications started, stopped, or adjusted (with dosing)
- Patient education and self-care instructions
- Referrals to specialists or ancillary services
- Follow-up interval and return precautions
Example
Continue ibuprofen 400 mg TID with food × 7 days. Begin PT 2×/week for 4 weeks (core stabilization, lumbar mobility). Educated on posture and lifting mechanics. Return in 4 weeks or sooner if weakness, numbness, or bladder changes develop.
Copy-ready blank template
SOAP NOTE Date: ____________ Patient: ____________ DOB: ____________ S — SUBJECTIVE Chief complaint: HPI: Medications / Allergies: Relevant history / ROS: O — OBJECTIVE Vitals: BP ___ / ___ HR ___ T ___°F RR ___ SpO2 ___% Physical exam: Labs / Imaging: Screening scores: A — ASSESSMENT Primary diagnosis (ICD-10): Differentials: Severity / Risk: Progress: P — PLAN Treatment / Procedures: Medications: Patient education: Referrals: Follow-up: Return precautions: Clinician signature: ____________________ Date: ________
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