General practice
General SOAP note template
The standard four-part clinical note used across primary care, urgent care and hospital medicine. Subjective, Objective, Assessment and Plan, with the level of detail auditors and colleagues expect.
Best used for
- Primary care visits
- Urgent care
- Ward rounds
- Telehealth follow-ups
Template structure
Each section shows what to document and a worked clinical example.
The patient's own account: presenting complaint, onset, duration, character, aggravating and relieving factors, relevant review of systems, and pertinent negatives.
Example
Three-day history of productive cough with yellow sputum and subjective fever. No chest pain, no haemoptysis, no leg swelling. Non-smoker. No recent travel.
Measurable findings only: vital signs, examination findings by system, point-of-care results and any imaging already reviewed.
Example
T 38.1 C, HR 96, BP 124/78, RR 18, SpO2 96% on air. Chest: coarse crackles right base, no wheeze. Heart sounds normal. No peripheral oedema.
A clinical impression, not a restatement of findings. Name the working diagnosis, note the differential you are actively excluding, and state severity or risk.
Example
Community-acquired pneumonia, right lower lobe, CRB-65 score 0 — suitable for outpatient management. Differential: acute bronchitis, less likely given focal findings and fever.
Investigations ordered, treatment started with dose and duration, patient education given, safety-netting advice and explicit follow-up interval.
Example
Chest radiograph today. Amoxicillin 500 mg three times daily for five days. Advised on fluids and antipyretics. Return immediately if breathless, confused or unable to keep fluids down. Review in 72 hours if not improving.
Documentation tips
- Write the assessment before the plan — the plan should follow logically from the impression.
- Record pertinent negatives; they demonstrate the differential you considered.
- State follow-up as an interval and a trigger, not just 'review PRN'.
Frequently asked questions
- What does SOAP stand for in a medical note?
- Subjective, Objective, Assessment and Plan — the four sections of the standard clinical progress note.
- How long should a SOAP note be?
- Long enough that another clinician could safely continue care. For a routine follow-up that is often under 200 words; for a complex new presentation it may be several hundred.
- Can ScribeMDPro generate this template automatically?
- Yes. ScribeMDPro drafts the full SOAP structure from the ambient recording of the consultation, and the clinician reviews and approves it before it is used.
- Is this template free to use?
- Yes, the template and example on this page are free to copy and adapt for your own documentation.
More templates
Let ScribeMDPro draft your general practice notes.
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