SOAP notes are used by physicians (MDs, DOs), nurse practitioners, physician assistants, therapists (physical, occupational, speech, mental health), chiropractors, registered nurses, and other allied health professionals. Any licensed clinician documenting a patient encounter may use SOAP format.

Are SOAP notes required by law?

While the SOAP format itself is not mandated by federal law, clinicians are legally and professionally required to document patient encounters. Medical boards, licensing bodies, malpractice insurers, and CMS all expect contemporaneous, accurate clinical documentation. Failure to document can result in professional discipline and increased malpractice liability.

Can SOAP notes be used for billing purposes?

Yes. SOAP notes support medical billing by documenting the medical necessity of services rendered. They are linked to CPT (Current Procedural Terminology) codes for services and ICD-10 codes for diagnoses. CMS and private insurers may audit medical records to verify that billed services are supported by adequate documentation.

What is the difference between a SOAP note and a DAP note?

DAP (Data, Assessment, Plan) notes are commonly used in mental health and counseling settings. Data replaces Subjective and Objective sections with a combined section documenting what occurred in the session. DAP notes tend to be less detailed on physical examination findings, which are less relevant in talk therapy settings. Both formats serve the same fundamental documentation purpose.

Free SOAP Note Template — Fill Out & Download Instantly

Free — No Sign-Up RequiredPDF & WordUpdated April 16, 2026

⚠️ Legal Disclaimer: This template is attorney-reviewed and built to US legal standards. It does not substitute for professional legal advice. For complex situations, we recommend consulting a licensed attorney.

Document Completeness0%

Practice / Facility Name*

Clinician Name*

Clinician Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Visit Date*

MM/DD/YYYY

Session Duration

S — Subjective*

Chief complaint, history of present illness, relevant past medical/social/family history

O — Objective*

Vital signs, physical exam findings, lab results, imaging findings

A — Assessment*

Clinical diagnosis or differential diagnoses, ICD-10 codes if applicable

P — Plan*

Treatment plan, prescriptions, referrals, patient education, follow-up

Note Date*

MM/DD/YYYY

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[Practice / Facility Name]

════════════════════════════════════════

CLINICAL PROGRESS NOTE — SOAP FORMAT

════════════════════════════════════════

Clinician: [Clinician Name], [Clinician Credentials]

Practice: [Practice / Facility Name]

Patient: [Patient Full Name] | DOB: [Patient Date of Birth]

Visit Date: [Visit Date]

S — SUBJECTIVE

[S — Subjective]

O — OBJECTIVE

[O — Objective]

A — ASSESSMENT

[A — Assessment]

P — PLAN

[P — Plan]

Clinician Signature: _______________________________

[Clinician Name], [Clinician Credentials]

Date: [Note Date]

CONFIDENTIAL MEDICAL RECORD — Protected Health Information

This document is protected under HIPAA (45 CFR Parts 160 and 164).

Unauthorized disclosure is prohibited.

Document Completeness0%

Practice / Facility Name*

Clinician Name*

Clinician Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Visit Date*

MM/DD/YYYY

Session Duration

S — Subjective*

Chief complaint, history of present illness, relevant past medical/social/family history

O — Objective*

Vital signs, physical exam findings, lab results, imaging findings

A — Assessment*

Clinical diagnosis or differential diagnoses, ICD-10 codes if applicable

P — Plan*

Treatment plan, prescriptions, referrals, patient education, follow-up

Note Date*

MM/DD/YYYY

What Is a SOAP Note Template?

A SOAP note is the standard structured format used by clinicians across medicine, nursing, therapy, and allied health to document patient encounters. SOAP stands for Subjective (patient-reported complaints, history, symptoms), Objective (measurable clinical findings, vitals, exam results), Assessment (clinical diagnosis or differential diagnoses), and Plan (treatment plan, prescriptions, referrals, and follow-up). This structured approach promotes clear, consistent documentation, facilitates communication between providers, supports billing and coding, and creates a legally defensible medical record.

When Do You Need It?

A SOAP note should be completed for every patient encounter that requires clinical documentation — routine office visits, follow-up appointments, telehealth visits, therapy sessions, and hospital progress notes. Clinicians are required to document each patient encounter as part of their professional and legal obligations. SOAP notes are also used for billing and coding (linked to CPT and ICD-10 codes), quality assurance, continuity of care, and as legal evidence in malpractice proceedings.

What's Included in This Template

Practice and clinician name with credentials
Patient name and date of birth
Visit date and session duration
Subjective section (chief complaint and history of present illness)
Objective section (vitals, physical exam findings, test results)
Assessment section (diagnosis, differential diagnoses)
Plan section (treatment, prescriptions, referrals, follow-up)
Note date and clinician signature block
Professional clinical documentation format

How to Fill It Out

Enter Clinician and Patient Information — Fill in the practice name, clinician's full name and credentials, patient's name and date of birth, and the date of the visit. Record the session duration if relevant for billing purposes.

Document the Subjective Section — In the subjective field, record the patient's chief complaint in their own words, the history of the present illness (onset, duration, character, severity, associated symptoms), and any relevant medical, surgical, family, or social history.

Document the Objective Section — In the objective field, record measurable, observable clinical findings: vital signs (BP, HR, temperature, weight), physical examination findings, laboratory results, imaging findings, and any other objective data collected during the encounter.

Complete Assessment and Plan, Then Sign — In the assessment field, state your clinical diagnosis or differential diagnoses. In the plan field, outline the treatment plan including medications prescribed, referrals, patient education, and follow-up instructions. Date and sign the note.

Legal Requirements & Notes

Clinical documentation including SOAP notes is part of the official medical record and may be used in malpractice litigation, billing audits, peer review, and regulatory investigations. Clinicians are legally and professionally obligated to document patient encounters accurately, completely, and in a timely manner. Medical records must be retained in accordance with applicable state law (typically 7–10 years for adults; longer for minors). Under HIPAA, patients have the right to access and request amendment of their medical records. In mental health settings, additional documentation requirements may apply under applicable state licensing board rules. Never alter or delete clinical records after the fact — corrections should be made as addenda with the date and clinician's initials.

Frequently Asked Questions

SOAP stands for Subjective (patient-reported complaints and history), Objective (measurable clinical findings from examination and tests), Assessment (the clinician's diagnosis or differential), and Plan (the treatment approach, prescriptions, referrals, and follow-up instructions). This structured format is the standard for clinical progress notes across most healthcare disciplines.

Free SOAP Note Template — Fill Out & Download Instantly

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CLINICAL PROGRESS NOTE — SOAP FORMAT

════════════════════════════════════════

S — SUBJECTIVE

O — OBJECTIVE

A — ASSESSMENT

P — PLAN

What Is a SOAP Note Template?

When Do You Need It?

What's Included in This Template

How to Fill It Out

Legal Requirements & Notes

Frequently Asked Questions

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