SOAP Note Examples for Physicians

These examples are fictional and short. They illustrate structure only; real notes carry more detail and follow your specialty and organization standards.

Example 1, primary care. S: 45-year-old with cough for five days, no fever, no shortness of breath. Non-smoker. O: Afebrile, SpO2 98% on room air, lungs clear, throat mildly erythematous. A: Acute viral upper respiratory infection. P: Supportive care, fluids, return if fever develops or symptoms last beyond ten days.

Example 2, cardiology follow-up. S: 67-year-old with heart failure, reports stable exertional dyspnea, no orthopnea, adherent to medications. O: BP 128/76, HR 68, weight stable from last visit, trace ankle edema, no JVD. A: Chronic heart failure, stable. P: Continue current regimen, repeat labs in three months, follow up in six months.

What both show: Subjective is what the patient reports, Objective is measured or observed, Assessment is the interpretation, and Plan is the action. Keeping those separate is the point of the format.

An AI scribe can draft this structure from the visit conversation. See the SOAP notes page and the AI SOAP note generator.