SOAP note template

You need a SOAP layout you can paste into your EMR today. Below is a blank template, a line-by-line guide to what each heading should hold, and a completed invented note to show the level of detail. At the end: how ClearPass drafts the same four headings from a visit so you only review and correct.

What goes under each of the four headings

SOAP splits a visit into what the patient reports, what you found, what you think, and what happens next. The value of the format is that a colleague can find any of those four things in seconds. That only works if each item sits under the right heading.

• Subjective: the presenting complaint in the patient's words, the history of that complaint (onset, duration, character, what helps, what worsens), relevant negatives, current medicines, allergies, and anything from the social or family history that changes the picture.
• Objective: measured and observed facts only. Vital signs, examination findings, point-of-care tests, and results that are available at the visit. No interpretation here.
• Assessment: your working diagnosis or problem, with the reasoning in one or two lines, and the differentials you considered. If it is a known condition, state whether it is controlled, improving or worse.
• Plan: investigations ordered, treatment started or changed, advice given, safety-netting (what should make the patient come back sooner), and when the next review is.

Blank SOAP template

SOAP NOTE
Date of visit: [date]
Visit type: [new problem / follow-up / telehealth]

S - SUBJECTIVE
Presenting complaint:
History of presenting complaint:
Relevant negatives:
Current medicines:
Allergies:
Relevant past, family and social history:

O - OBJECTIVE
Vital signs: BP / HR / RR / Temp / SpO2 / weight
Examination:
Point-of-care tests:
Results available today:

A - ASSESSMENT
Working diagnosis:
Reasoning:
Differentials considered:

P - PLAN
Investigations:
Treatment:
Advice and safety-netting:
Follow-up:

The same template, filled in

An invented adult with an ankle injury. Notice how the Objective section holds only findings, and the Plan says who does what and when.

S - SUBJECTIVE
29-year-old seen with right ankle pain after inverting the ankle playing five-a-side football yesterday evening. Able to walk four steps immediately after, limping since. Swelling over the outer ankle overnight. No previous injury to this ankle. No numbness. Paracetamol taken twice with partial relief. No regular medicines. No known drug allergies.

O - OBJECTIVE
BP 124/78, HR 72, afebrile.
Right ankle: swelling and bruising over the lateral malleolus. Tender over the anterior talofibular ligament. No bony tenderness at the posterior edge or tip of either malleolus, navicular or base of fifth metatarsal. Weight-bearing four steps in clinic. Foot warm, pulses present, sensation intact.

A - ASSESSMENT
Lateral ankle sprain, clinically low risk of fracture on examination; imaging not indicated today.

P - PLAN
Rest, ice, compression and elevation for 48-72 hours; weight-bear as pain allows.
Continue paracetamol as needed.
Ankle range-of-motion exercises sheet given.
Return sooner if unable to bear weight, increasing swelling, numbness or colour change.
Review in 2 weeks if not improving; consider physiotherapy then.

Common SOAP mistakes

• Putting interpretation in Objective, such as chest clear so no infection. Write the finding in Objective and the conclusion in Assessment.
• An Assessment that only repeats the complaint. Ankle pain is a symptom; lateral ankle sprain with low fracture risk is an assessment.
• A Plan with no follow-up interval or no safety-net advice. Those are the lines most often needed later.
• Copying the previous SOAP forward and editing only the date. Old examination findings end up looking as if they were found today.
• Leaving out relevant negatives. A missing negative reads the same as a question never asked.

How ClearPass drafts a SOAP note

In ClearPass you pick SOAP as the note structure, tap Transcribe, confirm the patient has agreed, and see the patient as usual. When you tap Stop, the conversation is turned into a draft under the four SOAP headings, written in English whatever language the visit was in. Choose Concise for key points only or Detailed if you want every clinical fact that was said.

The draft is a starting point. Numbers that appear in the note but were never said in the transcript are marked for you to check, and you correct anything wrong before copying the text into your EMR. Examination findings you do silently will not be in the transcript, so say them aloud or type them in. If you work from typed notes instead, paste them in and the same structure applies. For worked examples by condition see SOAP note for hypertension or the step-by-step guide on how to write a SOAP note.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Related

• SOAP note examples you can learn from
• How to write a SOAP note that colleagues can use
• SOAP note example: hypertension
• Progress note template
• Custom note templates: build headings that fit your clinic