GUIDES · 8 MIN READ
The SOAP note format, with a complete example
What goes in each section of a SOAP note — Subjective, Objective, Assessment and Plan — with a worked outpatient example and the mistakes that make notes harder to use.
The ScribeLive team ·
The SOAP note is the most common structure for outpatient documentation. It splits a visit into four parts so the next reader, whether that's you in three months, a colleague or a coder, can find what they need quickly.
The four sections
S — Subjective
What the patient tells you: the reason for the visit, the history of the present illness, relevant symptoms, medications they're taking, and anything else in their own words. Keep it to what's relevant to today's problems.
O — Objective
What you measure or observe: vital signs, examination findings, and results of tests available at the visit. If something wasn't examined, don't imply that it was.
A — Assessment
Your clinical interpretation: the diagnosis or differential for each problem, and how each chronic condition is doing. For visits with several problems, number them.
P — Plan
What happens next, for each problem: medications started, stopped or changed, tests ordered, referrals, patient education, and when to follow up.
A complete example
A follow-up visit for hypertension and type 2 diabetes, written problem by problem:
S: 58-year-old for 3-month follow-up. Home BP log averaging 132/84. Reports missing her evening metformin dose a few times a week. No chest pain, no dizziness. O: BP 138/86, pulse 76, weight stable. Feet: sensation intact. Most recent HbA1c 7.6%, up from 7.1%. A/P: 1. Essential hypertension — above target; increase lisinopril to 20 mg daily, recheck BMP in 2 weeks. 2. Type 2 diabetes — HbA1c rising with missed doses; discussed a pill organiser, recheck HbA1c in 3 months. 3. Hyperlipidemia — on atorvastatin, no side effects; continue, fasting lipids with next labs.
This example is illustrative, not clinical guidance.
Problem-oriented SOAP notes
Patients with several conditions rarely discuss them in order. A problem-oriented note combines Assessment and Plan and organises them by problem, so each condition gets its own assessment, plan and diagnosis code. It's easier to read at the next visit and easier to audit against a protocol.
Common mistakes
- Copy-forward clutter. Pasting last visit's note and editing it leaves stale findings behind.
- Findings that weren't done. Templates that default to “normal exam” document things nobody checked.
- A plan without owners or dates. “Recheck labs” is less useful than “HbA1c in 3 months”.
- Jargon in the patient's copy. The note is for clinicians; patients need a plain-language version. See plain-language visit summaries.
How an AI scribe drafts a SOAP note
An ambient AI scribe drafts each section from the visit conversation. ScribeLive drafts the full SOAP note, numbers assessment and plan points and links each to the moment it was said, suggests up to five ICD-10 codes, and leaves you to review and sign. You can also write or dictate any section yourself.
Frequently asked questions
What does SOAP stand for?
Subjective, Objective, Assessment and Plan: what the patient reports, what the clinician measures or observes, the clinician's interpretation, and what happens next.
What is the difference between subjective and objective in a SOAP note?
Subjective is what the patient tells you, in their words. Objective is what you measure or observe yourself, such as vital signs, exam findings and test results.
Should Assessment and Plan be combined?
For visits with several problems, many clinicians combine them and number each problem with its own assessment and plan. This problem-oriented format is easier to read and audit.