SOAP Notes Template

Elevate your clinical documentation, improving accuracy, productivity, and clinical outcomes.

By Audrey Liz Perez on Mar 18, 2024.

Fact Checked by RJ Gumban.

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What is a SOAP Note Template?

SOAP notes are a specific type of format structure for progress notes. This form of clinical documentation aims to track the improvement of patients, facilitate better communication between members of a patient’s care team, and provide evidence for insurance providers. SOAP notes separate information into four relevant sections:

Subjective: This section details the patient’s reporting of their chief complaint. Direct quotes from the patient are often included, as well as their symptoms and how the problem is impacting their day-to-day life.

Objective: The objective section includes the practitioner’s observation about the patient’s behavior and affect. It should also include details regarding any tests, examinations, scans or laboratory screenings that were completed during the session.

Assessment: The assessment is essentially a synthesis of the subjective and objective sections. It is where the practitioner provides an analysis or interpretation of the patient’s complaint, how the patient responded to treatment, and whether they are progressing towards their goals.

Plan: Finally, the plan section is where the practitioner writes the details of the patient’s future treatment. This could include upcoming sessions, referrals, changes to the treatment plan and any short- or long-term goals.

The SOAP format is clear, concise, and ensures practitioners include all important information. Further, the way it is structured makes it applicable to all kinds of healthcare, so regardless of what field you work in, you’ll be able to use SOAP notes.

Free SOAP Notes Template

Check out these free SOAP templates to elevate your clinical documentation, and improve accuracy, productivity, and clinical outcomes.

How to Use This SOAP Note Template PDF?

One of the best parts about using clinical SOAP notes is how easy it is to follow. This is why we’ve made sure that utilizing our PDF template will be similarly simple; helping you to streamline your note-taking process and save valuable time. 

Step One: Access the template 

First thing’s first: you need to access our PDF template. We’ve included a link on this page, and all you need to do is click on it and it will take you to the downloadable PDF. From here, you can save the template onto your device where it can be used whenever you need. 

Step Two: Credentials

At the top of the template, you’ll see there are certain credentials that need to be filled in, including the patient’s name and ID, and the date and time of the session. This information is required for compliance reasons, and it also helps accessing notes at a later date much easier. 

Step Three: Fill in the four SOAP sections

After you have a session with a client, it’s time to fill in each of the four SOAP sections. We’ve separated these clearly within the template, so all you need to do is include the relevant information pertaining to the session. 

Step Four: Save the document securely

Once you have completed your SOAP note, you need to store it somewhere safe. SOAP notes contain ePHI, meaning that under HIPAA guidelines, they need to be protected. You should apply password-protection and authorization protocols to your SOAP notes to ensure that your patient’s privacy is always protected.

SOAP Note Example (Sample)

Sometimes the best way to learn how to use a new resource is to see it in action, which is why we’ve created a sample SOAP note. So that you can visualize the type of information that is included within each section of the SOAP note, we’ve based this example off an individual counseling session. While the specific details that you include in your own SOAP notes will differ from this example, it should give you a more concise understanding of what the layout looks like in action. 

We have based this sample template off an individual counseling session with a patient.

Check out and download the SOAP Note example here:

SOAP note example

Who Can Use This SOAP Template?

SOAP notes are highly applicable to different fields of healthcare and we’ve made sure that this is the same for our template. Some of the different specializations that can use our SOAP note PDF template include:

  • Psychology
  • Psychiatry
  • Counseling
  • Physical Therapy
  • Occupational Therapy 
  • Massage Therapy 
  • Social Work
  • Chiropractic
  • Dentistry
  • Speech Therapy 
  • Acupuncture
  • Nursing

Additionally, our SOAP note template can be used for providers who work by themselves, as well as those who work within larger practices. The same flexibility is applicable to practitioners who have one-on-one sessions with clients and those who may work with groups (e.g. family counseling). Being able to use a SOAP note template that applies to a range of different healthcare fields is particularly useful as it assists with inter-department and inter-facility communication, leading to better coordination of care.

Why is This Template Useful for Medical Practitioners?

As I’m sure you know, medical practitioners are required to complete a wide range of different administrative and clinical tasks, all of which are time-consuming. Using our SOAP note template will be useful in a variety of ways, to help with the day-to-day workflow:

  • Save time: As we mentioned, administrative tasks can be very time-consuming. With our SOAP note template, you can significantly reduce the amount of time you spend writing your clinical notes, which can instead be spent completing more pressing tasks. 
  • Increase organization: Staying organized is important, but it can also be tricky when you’re juggling lots of work. Our SOAP note template does all of the organizing for you - all you have to do is fill in the relevant sections!
  • Track patient progress: At their core, SOAP notes are designed to track patient progress. With the four different sections, you can monitor how your patients are progressing and whether they are achieving their goals. This information will help you make more informed clinical decisions and amend treatment plans and diagnoses where necessary.
Soap note software feedback

Why Use Carepatron For SOAP note?

If you are looking to streamline your clinical documentation and save valuable time, then Carepatron is the perfect solution for you. In addition to offering useful and intuitive SOAP note templates, Carepatron is integrated with voice-to-text transcription software. This helps practitioners create their clinical notes in a more timely manner, without compromising the quality of the finished product. After you have finished writing your SOAP notes, you can store them using the Carepatron platform. Carepatron employs sophisticated and advanced encryption and authentication features to ensure your ePHI is protected at all times.

Carepatron doesn’t just stop at clinical documentation. The platform is also integrated with medical billing, appointment scheduling, automated reminders, online payments and client portals. A one-stop-shop, Carepatron can target all facets of your healthcare practice and ensure that both administrative and clinical processes are working smoothly. With state of the art software that is being continuously developed, Carepatron ensures that the technology your practice is using is not only the most recent, but just simply the best. Watch as the system saves you countless hours that can instead be spent doing what you do best: treating patients.

SOAP note template
Can patients see their SOAP notes?
Can patients see their SOAP notes?

Commonly asked questions

Can patients see their SOAP notes?

Yes, it is a requirement under law that patients can access their SOAP notes. It is very important, then, that the information you include is truthful and accurate. You should avoid using any kind of judgemental language, and keep abbreviations and medical jargon to a minimum. Improving the transparency of the healthcare system is a difficult thing to achieve, but having accessible and appropriate SOAP notes is definitely a good place to start.

How long should my SOAP notes be?

This is a tricky question to answer. A good rule of thumb is around 1-2- pages; you don’t want to omit important details, but you also don’t want to be overly wordy. The content of the session will influence the length of the SOAP note - if you change the treatment plan or conduct extensive assessments, then it is reasonable to assume that SOAP note will be longer than is typical.

Can I handwrite SOAP notes?

Yes, you can handwrite SOAP notes, however we wouldn’t recommend it. Typing and storing your SOAP notes online is a preferred option; you are less likely to lose the documentation, it is more easily accessed, and online encryption is one of the best safeguards for protecting ePHI. At the end of the day, whether you write your notes by hand or online is up to you, but we definitely recommend looking into the advantages of using an EHR platform.

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