SOAP Notes: Structure, Example and How AI Drafts Them
A SOAP note is a structured clinical note with four sections: Subjective (what the patient reports), Objective (what the clinician observes and measures), Assessment (the clinical impression) and Plan (what happens next).
Last reviewed October 6, 2026
What goes in each section
- Subjective: chief complaint, history of present illness, relevant history, medications, allergies.
- Objective: vitals, exam findings, test and imaging results.
- Assessment: diagnoses or differential, with clinical reasoning.
- Plan: orders, prescriptions, referrals, patient instructions, follow-up.
A short fictional example
S: 34-year-old with three days of sore throat and low-grade fever. No cough. No known allergies.
O: Temp 100.4 F. Tonsillar erythema with exudate. Anterior cervical nodes tender. Rapid strep positive.
A: Streptococcal pharyngitis.
P: Amoxicillin for 10 days. Fluids and rest. Return if no improvement in 48 hours.
How AI helps
An AI scribe drafts the four sections from the visit conversation so you review instead of write. See the AI SOAP note generator for how MD Record AI does this.
Frequently asked questions
Why SOAP format?
It gives every note the same predictable order, which makes notes faster to write and easier for colleagues to read.
Does the example show a real patient?
No. It is fictional and only illustrates the structure.