SOAP Note Examples
Complete, real-world clinical documentation examples with section-by-section breakdowns for every practice type.
SOAP notes are the standard format for clinical documentation across healthcare and wellness disciplines. Whether you're a massage therapist, chiropractor, psychotherapist, or veterinarian, well-written SOAP notes protect your practice, support insurance reimbursement, and ensure continuity of care. Below you'll find over 20 complete examples organized by specialty and note format, each with a detailed breakdown of what to include and why.
SOAP Note Examples by Specialty
Complete Subjective, Objective, Assessment, and Plan documentation for 20 practice types.
Massage Therapy
Below is a complete SOAP note example for a 60-minute massage therapy session treating chronic lower back pain. Each section is broken down with explanations of what to include and why.
View Example →Chiropractic
Below is a complete SOAP note example for a chiropractic visit treating cervical pain following a motor vehicle accident. This example demonstrates proper documentation of adjustments, objective measurements, and treatment planning.
View Example →Acupuncture
Below is a complete SOAP note example for an acupuncture session treating chronic migraine headaches with a TCM pattern of Liver Qi Stagnation with Liver Yang Rising. This example shows how to bridge TCM diagnosis with Western-style documentation.
View Example →Physical Therapy
Below is a complete SOAP note example for a physical therapy session treating a patient 6 weeks post-operative left ACL reconstruction with patellar tendon autograft. This example demonstrates proper documentation of objective measurements, functional assessments, and evidence-based treatment planning for post-surgical rehabilitation.
View Example →Mental Health Counseling
Below is a complete SOAP note example for an individual therapy session with a client diagnosed with Generalized Anxiety Disorder (GAD). This example demonstrates proper documentation of the mental status exam, cognitive behavioral therapy interventions, standardized outcome measures, risk assessment, and treatment planning in a counseling setting.
View Example →Nursing
Below is a complete SOAP note example for a registered nurse documenting a follow-up visit with a patient newly diagnosed with Type 2 diabetes mellitus. This example demonstrates thorough nursing assessment, vital signs documentation, focused physical exam findings, patient education with teach-back, medication reconciliation, and interdisciplinary care coordination.
View Example →Occupational Therapy
Below is a complete SOAP note example for an occupational therapy session treating a stroke survivor focused on upper extremity function and return to independence with activities of daily living. This example demonstrates proper documentation of standardized assessments, functional performance measures, and skilled intervention planning.
View Example →Speech-Language Pathology
Below is a complete SOAP note example for a speech-language pathology session treating a 5-year-old child with a moderate articulation disorder. This example demonstrates proper documentation of phonological process analysis, stimulability testing, intelligibility estimates, parent report, and evidence-based intervention planning.
View Example →Social Work
Below is a complete SOAP note example for a clinical social work session with an adult client experiencing housing instability and depression. This example demonstrates proper documentation of biopsychosocial assessment, standardized screening measures, safety evaluation, systems-level intervention, and resource coordination.
View Example →Psychotherapy
Below is a complete SOAP note example for an individual psychotherapy session using Eye Movement Desensitization and Reprocessing (EMDR) therapy to treat post-traumatic stress disorder. This example demonstrates proper documentation of EMDR-specific protocols, target memory identification, Subjective Units of Disturbance (SUD) and Validity of Cognition (VOC) scales, bilateral stimulation, and phase progression.
View Example →Pediatrics
Below is a complete SOAP note example for a 4-year-old well-child visit including developmental screening, growth assessment, immunization review, and anticipatory guidance. This example demonstrates proper documentation of caregiver-reported history, age-appropriate exam findings, and pediatric-specific treatment planning.
View Example →Telehealth
Below is a complete SOAP note example for a telehealth follow-up visit with an adult patient managing generalized anxiety disorder via video-based care. This example demonstrates proper documentation of telehealth-specific elements including informed consent, technology platform, patient location, audio/video quality, and the modified physical assessment approach required for remote encounters.
View Example →Group Therapy
Below is a complete SOAP note example for an individual participant in a grief and loss support group. This example demonstrates how to document individual clinical progress within a group therapy context, including group dynamics, peer interactions, participation level, session structure, and individual treatment goals.
View Example →Psychiatry
Below is a complete SOAP note example for a psychiatry medication management visit with an adult patient diagnosed with major depressive disorder. This example demonstrates proper documentation of a full mental status exam, standardized outcome measures, current medications with doses, side effect assessment, medication adjustment rationale, and laboratory monitoring.
View Example →Veterinary
Below is a complete SOAP note example for a veterinary visit evaluating a 7-year-old Golden Retriever presenting with acute right hindlimb lameness. This example demonstrates proper documentation of species-specific signalment, owner-reported history, orthopedic examination findings, radiographic interpretation, and a weight-based treatment plan.
View Example →Pain Management
Below is a complete SOAP note example for a pain management visit with an adult patient receiving multimodal treatment for chronic low back pain, including a lumbar epidural steroid injection and ongoing medication management. This example demonstrates proper documentation of pain assessment scales, opioid risk stratification, PDMP verification, procedural documentation, and a comprehensive treatment plan.
View Example →Urgent Care
Below is a complete SOAP note example for an urgent care visit evaluating an adult patient presenting with acute pharyngitis. This example demonstrates efficient documentation appropriate for a high-volume clinical setting while maintaining thorough medical decision-making, Centor criteria scoring, rapid diagnostic testing, and clear discharge instructions with return precautions.
View Example →Dermatology
Below is a complete SOAP note example for a dermatology visit evaluating a suspicious pigmented lesion on an adult patient. This example demonstrates proper documentation of lesion morphology using standardized dermatologic terminology, ABCDE criteria assessment, dermoscopic findings, shave biopsy procedural documentation, and pathology follow-up planning.
View Example →Naturopathy
Below is a complete SOAP note example for a naturopathic medicine visit addressing chronic fatigue and digestive complaints. This example demonstrates proper documentation of a whole-person assessment including dietary history, lifestyle factors, laboratory evaluation, and an integrative treatment plan combining botanical medicine, nutritional supplementation, and lifestyle modification.
View Example →Health Coaching
Below is a complete SOAP note example for a health coaching session focused on weight management and lifestyle behavior change. This example demonstrates proper documentation of client-reported progress, motivational interviewing techniques, readiness-to-change assessment, and collaborative goal setting using SMART criteria.
View Example →DAP & BIRP Note Examples
Alternative documentation formats commonly used in mental health and counseling settings. DAP notes combine subjective and objective data into a single section, while BIRP notes focus on the connection between clinical interventions and client responses.
Mental Health Counseling
A DAP note is a streamlined clinical documentation format used widely in mental health counseling, social work, and psychotherapy. DAP stands for Data, Assessment, and Plan. The Data section combines both subjective and objective information from the session into a single narrative, the Assessment section captures the clinician's clinical interpretation and diagnostic reasoning, and the Plan section outlines next steps for treatment. DAP notes are popular among mental health professionals because they reduce redundancy and allow the clinician to weave the client's self-report together with observed behavior in one cohesive section. Below is a complete DAP note example for an individual counseling session with an adult client presenting with generalized anxiety disorder, treated using cognitive behavioral therapy techniques.
View Example →Mental Health Counseling
A BIRP note is a structured clinical documentation format commonly used in mental health counseling, substance abuse treatment, and community mental health settings. BIRP stands for Behavior, Intervention, Response, and Plan. The Behavior section documents the client's observable presentation and self-reported concerns, the Intervention section details the specific clinical techniques the therapist used during the session, the Response section captures how the client reacted to those interventions, and the Plan section outlines the next steps in treatment. BIRP notes are valued for their clear cause-and-effect structure — they make it easy to demonstrate that the interventions used were clinically appropriate and that the client is responding to treatment. Below is a complete BIRP note example for an individual counseling session with an adult client presenting with major depressive disorder, treated using motivational interviewing and behavioral activation techniques.
View Example →Frequently Asked Questions
What is a SOAP note?
A SOAP note is a structured method of clinical documentation used by healthcare providers. SOAP stands for Subjective (patient's reported symptoms and history), Objective (measurable clinical findings), Assessment (clinical interpretation and diagnosis), and Plan (treatment plan and follow-up). This standardized format ensures thorough, consistent documentation across all healthcare disciplines.
What are the 4 sections of a SOAP note?
The four sections are: Subjective — the patient's own report of symptoms, concerns, and history; Objective — measurable data like vital signs, exam findings, and test results; Assessment — the clinician's diagnosis or clinical impression based on the subjective and objective findings; and Plan — the treatment plan including interventions, referrals, medications, and follow-up instructions.
What is the difference between SOAP, DAP, and BIRP notes?
SOAP notes use four sections (Subjective, Objective, Assessment, Plan). DAP notes combine the subjective and objective sections into a single Data section, making them popular in mental health settings. BIRP notes use Behavior, Intervention, Response, and Plan — focusing on observable behavior and documenting the direct connection between the clinician's intervention and the client's response. All three formats serve the same purpose of structured clinical documentation.
How do I write a SOAP note for the first time?
Start by documenting the patient's reported symptoms and history (Subjective), then record your measurable findings from the examination (Objective). Next, write your clinical interpretation and diagnosis (Assessment), and finally outline the treatment plan (Plan). Review the specialty-specific examples on this page for guidance on what to include in each section for your practice type.
Can I use AI to write SOAP notes?
Yes. AI-powered tools like Wellistic generate professional SOAP notes from a brief session summary. You describe what happened during the session, and the AI produces a complete, structured note in seconds. This saves significant documentation time while maintaining clinical accuracy. You always review and edit the generated note before finalizing.
Are SOAP notes required for insurance billing?
Yes, in most cases. Insurance companies and third-party payers require clinical documentation to support medical necessity for the services billed. SOAP notes provide the structured evidence needed to justify treatment, demonstrate ongoing progress, and support reimbursement claims. Incomplete or missing documentation is one of the most common reasons for claim denials.
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