SOAP Note Template (Veterinary)
Published: 10/22/2025
About this template:
This veterinary SOAP note template helps document animal patient visits efficiently. It provides structure for recording physical examination findings, diagnostic test results, treatment interventions, and client communication. The template supports comprehensive documentation across species and conditions, from routine wellness visits to complex medical cases, ensuring thorough records for ongoing veterinary care.
Preview template
Subjective: “Max”, a 7-year-old male neutered Labrador Retriever, presents for decreased appetite and lethargy for 3 days. Owner reports one episode of vomiting yesterday (undigested food). No diarrhea. Drinking water normally. No known toxin exposure or dietary indiscretion. Up to date on vaccinations. Takes joint supplements, no other medications. Activity level decreased, reluctant to go on walks.
Objective: Weight 32.4 kg (body condition score 6/9). Temperature 103.2°F, heart rate 108 bpm, respiratory rate 28 breaths/min. Mucous membranes pink and moist, capillary refill time <2 seconds. Mild dehydration (approximately 5%). Abdominal palpation reveals discomfort in cranial abdomen, no masses palpated. Rectal examination normal. Auscultation reveals normal heart and lung sounds. Dental examination shows moderate tartar accumulation.
Assessment and Plan:
- Acute gastroenteritis, etiology to be determined
- Mild dehydration
- Diagnostic tests performed: Complete blood count shows mild leukocytosis (18,000), chemistry panel reveals mildly elevated lipase
- Abdominal radiographs show no evidence of foreign body or obstruction
- Treatment initiated: Subcutaneous fluids (500ml LRS), maropitant injection for nausea, metronidazole for suspected bacterial gastroenteritis
- Bland diet prescribed (boiled chicken and rice) for 3-5 days
Owner Education:
- Discussed home care including monitoring for continued vomiting, diarrhea, or worsening lethargy
- Instructed to offer small, frequent meals and ensure access to fresh water
- Administered medications demonstrated, written instructions provided
- Reviewed signs requiring immediate veterinary attention (continued vomiting, bloody stool, collapse)
Recheck examination scheduled in 3 days if not improved sooner. Owner instructed to call with any concerns or if condition worsens. Owner verbalizes understanding of diagnosis, treatment plan, and home care instructions.
