SOAP Note Template
Published: 10/20/2025
What is a SOAP note?
A SOAP note is a standardized method for documenting patient encounters used across healthcare settings. SOAP stands for Subjective, Objective, Assessment, and Plan - four sections that organize clinical information in a logical, consistent format.
Whether you're a physician, nurse practitioner, physical therapist, or mental health professional, mastering SOAP notes is essential for quality patient care, legal protection, and efficient documentation.
Scope's AI medical scribe can help with this as well, by capturing patient encounters in real-time and generating high-quality clinical notes.
Free SOAP Note Templates
View Family Medicine Template →
Developed by a family medicine clinician, this template helps you capture a full picture of the first visit, covering history, exam, pertinent tests, and social context. It supports a whole person approach while guiding you to a clear assessment and a detailed plan, so diagnoses, treatments, and follow up steps are documented coherently from the start.
View Internal Medicine Template →
Made for internists managing complex adult patients, this template streamlines documentation of multi-system evaluations, chronic disease management, and diagnostic reasoning for hospital and outpatient settings.
Created for pediatricians, this template captures growth milestones, developmental assessments, and family-centered care while documenting age-appropriate treatments from newborns to adolescents.
Built for psychiatrists, this template documents mental status exams, medication management, and treatment progress while supporting diagnostic clarity and therapeutic interventions.
Designed for therapists and counselors, this template captures session dynamics, therapeutic interventions, and client progress using a psychodynamic approach to document emotional and behavioral changes.
Created for cardiologists, this template streamlines documentation of cardiovascular assessments, diagnostic testing, and treatment plans for both acute and chronic cardiac conditions.
Established for dermatologists, this template documents skin conditions, lesion characteristics, and treatment protocols while supporting accurate diagnosis and procedural documentation.
Customized for chiropractors, this template documents musculoskeletal assessments, spinal adjustments, and treatment progress while tracking functional improvements and patient response.
View Physical Therapy Template →
Created for physical therapists, this template tracks patient progress, exercise compliance, and functional outcomes while documenting evidence-based interventions and home program adherence.
Formed for dental professionals, this template documents oral health assessments, periodontal status, and treatment plans while capturing the complete oral condition of each patient.
Crafted for veterinarians, this template documents animal patient assessments, diagnostic findings, and treatment plans while supporting clear communication with pet owners.
How AI can simplify clinical notetaking
AI is changing the game for SOAP notes—what used to be manual documentation is now turning into guided workflows, built right into your EHR.
With tools like Scope's AI medical scribe, notes get done faster, stay more consistent, and hold up better when audits come around.
Right there in the chart, Scope's AI-assisted prompts and structured fields make sure you're covering everything clearly. That cuts down on the missed details and inconsistencies that can lead to claim denials.
The bottom line? Cleaner claims and less hassle. Scope's AI medical scribe helps you document accurately and on time, while you stay the one signing off on the notes and your EHR keeps everything compliant. It's also completely free for US healthcare professionals.
Frequently Asked Questions
What's the fastest way to complete SOAP notes?
The fastest method is using an AI medical scribe like Scope Health that listens to your patient visits and generates complete SOAP notes automatically. This eliminates the manual typing process entirely, allowing you to focus on patient care while Scope handles the documentation in real-time.
Can I customize SOAP note templates for different specialties?
Absolutely. Different medical specialties require different documentation approaches. Scope allows you to build custom templates tailored to your specialty - whether you're in primary care, cardiology, dermatology, or any other field. Each template can include specialty-specific sections, terminology, and workflows that match how you actually practice.
Do SOAP notes have to follow a strict format?
While SOAP provides the standard four-section framework, there's flexibility in how detailed each section needs to be. Simple acute visits might have brief notes, while complex cases require more thorough documentation. The important part is capturing all clinically relevant information. Scope Health adapts to your documentation style while maintaining the structure required for compliance and billing.
How can I reduce time spent on documentation?
Most clinicians spend 2-3 hours daily on notes. Using Scope Health's ambient AI technology cuts this dramatically - many providers report saving 2+ hours per day. The system captures your patient conversation, structures it into proper SOAP format, and lets you review and sign off in seconds rather than spending 10-15 minutes per note.
