SOAP Note Examples for Common Ambulatory Visits
Realistic, anonymised SOAP note examples for common ambulatory presentations, with commentary on what a strong note includes and omits.
Example 1 — Adult upper respiratory infection
S: 34-year-old with 3 days of sore throat, nasal congestion, and dry cough. No fever, no dyspnoea. No exposure to confirmed COVID. Immunocompetent.
O: T 37.1, HR 78, BP 118/72, SpO2 99%. Oropharynx erythematous, no exudate. Chest clear. Nasal mucosa boggy.
A: Likely viral URI.
P: Symptomatic management — analgesia, hydration, saline nasal spray. Return if fever > 38.5, worsening dyspnoea, or symptoms > 10 days. Patient information leaflet provided.
Example 2 — Paediatric asthma follow-up
S: 9-year-old, 4 weeks post step-up to ICS/LABA. Parent reports no night symptoms, no reliever use in past 7 days, full school attendance.
O: Chest clear, no wheeze. Inhaler technique observed — adequate. PEFR at personal best.
A: Well-controlled asthma on step-up therapy.
P: Continue current regimen. Review in 8 weeks. Asthma action plan updated and given to parent.
Frequently asked questions
- Can I copy these into my EHR?
- The examples are illustrative and anonymised. Use them as structure, not as substitute clinical judgement.
The ScribeMDPro editorial team researches and edits every article to our editorial and medical-accuracy standards before publication.
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