Free SOAP Note Generator
Generate complete, professional SOAP notes for any healthcare or clinical setting. Our general template adapts to your keywords and produces documentation suitable for a wide range of practice contexts.
What is a SOAP Note?
A SOAP note is a structured method of clinical documentation used by healthcare professionals worldwide. Developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record, the SOAP format has become the standard for documenting patient encounters across virtually every healthcare discipline.
SOAP stands for Subjective, Objective, Assessment, and Plan. Together, these four sections create a comprehensive, organized record of a clinical encounter that supports continuity of care, clinical decision-making, and legal documentation.
The Four Sections
S - Subjective
What the patient or client reports. This includes their chief complaint, symptoms in their own words, relevant history, and how they perceive their condition. This section captures the patient's perspective and lived experience.
O - Objective
What the clinician observes and measures. This includes physical findings, vital signs, test results, standardized assessment scores, and observable behaviors. This section contains factual, measurable data.
A - Assessment
The clinician's analysis and clinical judgment. This connects the subjective and objective data, provides a clinical impression, evaluates progress, and may include diagnostic considerations. This is where critical thinking is documented.
P - Plan
The action items going forward. This includes treatment plans, referrals, follow-up schedules, medication changes, patient education, and any other next steps. This section drives continuity of care.
Who Uses SOAP Notes?
Social Workers
Case management, assessments, referrals
Therapists and Counselors
Session documentation, treatment planning
Nurses
Patient assessments, care coordination
Mental Health Professionals
Psychiatric assessments, medication management
Physical Therapists
Rehabilitation, functional mobility
Occupational Therapists
ADL training, adaptive equipment
General SOAP Note Example
S - Subjective
Patient is a 35-year-old male presenting for a follow-up visit regarding lower back pain that began approximately three weeks ago after lifting heavy boxes during a move. He reported that the pain has been gradually improving with use of ibuprofen 400mg as needed, approximately 2-3 times daily. He described the pain as a dull ache rated 3/10 at rest and 5/10 with prolonged sitting. He denied any radiating pain, numbness, tingling, or bowel/bladder changes.
O - Objective
Patient appeared comfortable and in no acute distress. Lumbar range of motion was improved compared to the initial visit, with flexion approximately 80% of normal. Mild tenderness to palpation over the L4-L5 paraspinal muscles bilaterally. Straight leg raise test was negative bilaterally. Lower extremity strength was 5/5 bilaterally. Gait was normal and steady. Sensation intact in all dermatomes of the lower extremities.
A - Assessment
Patient's mechanical low back pain is improving with conservative management. The improvement in range of motion, absence of neurological findings, and decreasing pain levels suggest a musculoskeletal strain that is resolving appropriately. No red flag symptoms identified.
P - Plan
Continue ibuprofen 400mg as needed for pain, not to exceed 3 doses daily. Begin core strengthening exercises as tolerated. Provided written instructions for lumbar stretching program. Patient to return in four weeks if symptoms have not fully resolved, or sooner if symptoms worsen or neurological symptoms develop. Discussed ergonomic lifting techniques for prevention.