SOAP Note Example
Veterinary SOAP Note Example
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.
Complete Veterinary Note
SUBJECTIVE:
Patient is a 7-year-old male neutered Golden Retriever, 36.2 kg, presenting for acute onset right hindlimb lameness noticed by the owner 3 days ago. Owner reports the patient was playing fetch in the backyard when he suddenly yelped, pulled up on the right hind leg, and refused to bear weight. Over the following 24 hours the patient began partially weight-bearing but has remained consistently lame with a noticeable limp, worst first thing in the morning and after rest. Owner reports the patient is reluctant to jump onto the couch or into the car, activities he previously performed without hesitation. Appetite is normal, drinking water normally, urination and defecation normal in frequency and character. No vomiting or diarrhea. Owner denies any known trauma beyond the fetching episode, no access to toxins, no known foreign body ingestion. No history of prior lameness or orthopedic surgery. Vaccination status: current on DHPP, rabies, Bordetella, and canine influenza. Heartworm prevention: monthly oral ivermectin/pyrantel (current). Flea and tick prevention: monthly isoxazoline (current). No current medications. Diet: adult large-breed maintenance kibble, 2 cups twice daily. No known drug sensitivities. Previous medical history: bilateral ear infections treated with otic antibiotics (2024), otherwise unremarkable.
OBJECTIVE:
General physical examination: body condition score 7/9 (overweight), temperature 101.8°F (normal 100.0–102.5°F), heart rate 96 bpm (normal 60–140 bpm), respiratory rate 22 breaths per minute (normal 10–30), mucous membranes pink and moist, CRT less than 2 seconds, peripheral lymph nodes within normal limits on palpation, auscultation — no heart murmur detected, lungs clear bilaterally, abdominal palpation soft and non-painful with no organomegaly or masses appreciated. Orthopedic examination: gait analysis — grade 3/5 right hindlimb lameness at the walk (consistent weight-bearing lameness with visible head bob and shortened stride), grade 4/5 at the trot (intermittent non-weight-bearing). Standing posture: shifting weight to left hindlimb, right hindlimb held in slight flexion. Right stifle palpation: moderate joint effusion (ballotable), medial buttress palpable, positive cranial drawer test (3-4 mm cranial translation with soft endpoint), positive tibial thrust test. Pain response elicited on stifle hyperextension. Range of motion: right stifle flexion 40° (left 38°, normal), right stifle extension 150° (left 162°), reduced extension with pain at end range. No crepitus detected. Left stifle: no drawer, no thrust, no effusion, full ROM without pain — normal. Hip examination bilateral: Ortolani test negative bilaterally, full ROM without crepitus or pain, no joint laxity detected. Tarsus and digits bilateral: no swelling, instability, or pain on palpation and ROM testing. Neurological screening: proprioceptive placing normal all four limbs, withdrawal reflexes intact, patellar reflexes 2+ bilaterally (normal). Radiographs — right stifle (lateral and caudocranial views): moderate joint effusion with caudal displacement of the fascial plane between the gastrocnemius and the joint capsule (positive fat pad sign), mild osteophyte formation on the proximal trochlear ridges and caudal tibial plateau, cranial displacement of the tibial tuberosity relative to the femoral condyles consistent with cranial cruciate ligament rupture, no fractures or lytic lesions identified, meniscal mineralization not visualized. Left stifle radiographs (lateral): no effusion, no degenerative changes, normal alignment for comparison.
ASSESSMENT:
Right cranial cruciate ligament (CCL) rupture is the primary diagnosis, supported by positive cranial drawer and tibial thrust tests, moderate stifle effusion, radiographic evidence of cranial tibial displacement, and acute onset lameness in a large-breed middle-aged dog — a classic signalment for CCL disease. Radiographic evidence of early osteophyte formation suggests the ligament may have undergone partial degeneration prior to the acute complete rupture during activity. Concurrent meniscal injury cannot be ruled out based on physical examination and radiographs alone — approximately 40-60% of dogs with CCL rupture have concurrent medial meniscal tears, and definitive meniscal assessment requires surgical exploration or MRI. The patient's body condition score of 7/9 (overweight) is a contributing factor to joint stress and will need to be addressed as part of the comprehensive treatment plan. The contralateral left stifle is currently normal on examination and radiographs, but given that 40-60% of dogs with unilateral CCL rupture develop contralateral rupture within 1-2 years, monitoring will be essential. Prognosis for return to comfortable function is good with surgical stabilization.
PLAN:
Surgical referral: consultation with veterinary surgeon Dr. Kowalski for tibial plateau leveling osteotomy (TPLO) of the right stifle — referral form submitted and surgical consultation scheduled for 03/05/2026. Pre-surgical blood work ordered: complete blood count, serum chemistry panel, and coagulation profile to confirm anesthetic candidacy. Immediate medical management while awaiting surgery: carprofen 2.2 mg/kg PO BID with food (36.2 kg = 79.6 mg per dose, dispensed 75 mg tablets, give 1 tablet by mouth twice daily with meals for 14 days), gabapentin 5 mg/kg PO BID (36.2 kg = 181 mg per dose, dispensed 100 mg capsules, give 2 capsules by mouth twice daily for 14 days for multimodal analgesia). Activity restriction: strict leash walks only for elimination (5 minutes maximum), no running, jumping, stairs, or off-leash activity; confine to a small room or exercise pen when unsupervised. Weight management plan initiated: target weight 30-32 kg (approximately 15% reduction), transition to a veterinary weight-management diet over 7 days, reduce current intake by 20%, reweigh in 4 weeks. Recheck appointment in 2 weeks to reassess lameness, monitor NSAID tolerance (watch for decreased appetite, vomiting, dark tarry stool), and review pre-surgical blood work results. Owner instructed to monitor for worsening lameness, sudden refusal to bear weight (may indicate meniscal injury progression), or any adverse medication effects and to contact the clinic immediately if observed.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
In veterinary SOAP notes, the subjective section documents the signalment (species, breed, age, sex, reproductive status, and body weight) and the owner's report of the presenting complaint, since the patient cannot self-report. Include the onset, duration, and progression of symptoms along with any observed changes in activity, appetite, elimination, and behavior. Document the patient's vaccination status, parasite prevention, diet, current medications, and known drug sensitivities — this information is essential for anesthetic planning and drug selection. Previous medical and surgical history provides context for differential diagnoses and informs the treatment approach.
Objective
The veterinary objective section requires a systematic physical examination with species-appropriate vital parameters and a body condition score. For orthopedic cases, document gait analysis with a standardized lameness grading scale, and describe each provocative test performed (cranial drawer, tibial thrust, Ortolani) with specific findings including degree of translation and endpoint quality. Always examine the contralateral limb for comparison. Include radiographic interpretation with specific findings — joint effusion indicators, osteophyte location, alignment abnormalities, and the absence of other pathology such as fractures or neoplasia. This level of detail is necessary for surgical referral documentation and client communication.
Assessment
The veterinary assessment should state the primary diagnosis and list the specific examination and diagnostic findings that support it. Discuss differential diagnoses that have not been fully excluded, such as concurrent meniscal injury, and explain what additional diagnostics would be needed to rule them in or out. Address contributing factors like obesity that affect prognosis and treatment. Include breed-specific disease prevalence data and contralateral limb risk when relevant, as this helps set owner expectations and justifies a long-term monitoring plan. State the prognosis clearly so it can be referenced when discussing treatment options and costs with the owner.
Plan
Veterinary treatment plans must include all medication dosages calculated per kilogram of body weight with the actual dose dispensed in tablet or capsule form, since owners administer medications at home. Document the specific surgical procedure recommended, the referral details, and any pre-surgical diagnostics ordered. Activity restriction instructions must be practical and specific — owners need concrete guidance like 'leash walks for elimination only, 5 minutes maximum' rather than vague instructions to 'rest.' Weight management targets with a specific percentage goal and dietary transition plan are essential when obesity is a contributing factor. Include specific monitoring parameters and adverse effect signs the owner should watch for, along with clear instructions on when to seek emergency care.
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