Below are eight complete SOAP notes, one each for a dietitian, health coach, functional medicine practitioner, counselor, physical therapist, occupational therapist, massage therapist, and chiropractor. Each shows all four sections written out, so you can see how the same structure changes shape across disciplines.
Every example here is illustrative. The clients are composites written to demonstrate the format, and none is a real person or a real record.
For the mechanics of writing each section, see how to write a SOAP note. This page is the example set.
A SOAP note is a client record written in four sections, subjective, objective, assessment, and plan, where each section does a job the others do not.
| Section | The question it answers | Written by |
|---|---|---|
| Subjective | What did the client report? | The client, in their words |
| Objective | What did you measure or observe? | Your instruments and your eyes |
| Assessment | What does it mean? | Your clinical reasoning |
| Plan | What happens next? | You, with dates and amounts |
The failure that shows up in weak notes is the assessment restating the two sections above it. When that happens, three sections are doing one job and the note carries no reasoning.
Composite scenario: third visit, weight management and blood sugar goals.
S: Client reports sticking to the meal structure on weekdays and losing it on weekends. Describes strong afternoon cravings around 3pm, four or five days a week. Energy improved since the last visit. Sleeping 6 to 7 hours, up from 5. Reports no changes to medication.
O: Weight 186 lb, down 3 lb from 189 lb four weeks ago. Waist 38 in, down 1 in. Three-day food record shows average 1,650 kcal, protein averaging 62 g per day against the 100 g target. Fasting glucose log averages 112 mg/dL, down from 124 mg/dL.
A: Steady progress toward the weight goal at a safe rate. The afternoon craving pattern lines up with low protein at breakfast and lunch, averaging 20 g across both meals. Weekend structure is the main gap, and glucose is trending down in line with the weight change.
P: Raise breakfast protein to 30 g, with three specific options given. Add a mid-afternoon protein snack. Client to log weekends only for the next two weeks. Recheck weight, waist, and glucose log at the next visit in four weeks. Send the protein guide through the client portal today.
Composite scenario: week six of a twelve-week habit program.
S: Client reports the morning walk is now automatic and no longer needs a reminder. Describes the evening screen habit as unchanged. Reports one high-stress week at work and says the walk held through it, which surprised them.
O: Walk logged 6 of 7 days, up from 4 of 7 in week three. Screen-time entry blank for 5 of 7 days. Weekly check-in form completed on time. Self-rated stress 7 of 10, up from 5 of 10.
A: The walking habit is established, and holding it through a high-stress week is the strongest signal so far. The screen habit has no attachment point yet, which is why logging keeps lapsing. Rising stress is a risk to both.
P: Leave the walk alone and stop logging it. Attach the screen limit to an existing cue: phone on the charger in the kitchen when the dishwasher goes on. Add a two-minute wind-down to the evening check-in. Revisit stress at the next session in one week.
Composite scenario: follow-up after lab review, fatigue and digestive complaints.
S: Client reports fatigue improved from 8 of 10 to 5 of 10 since starting the protocol eight weeks ago. Bloating now occurs 2 days a week, down from daily. Reports one flare after a restaurant meal. Adherence to the elimination phase described as roughly 80 percent.
O: Ferritin 42 ng/mL, up from 18 ng/mL. Vitamin D 38 ng/mL, up from 22 ng/mL. hs-CRP 2.1 mg/L, down from 4.8 mg/L. Weight stable at 142 lb. Symptom tracker shows bloating clustered on days with reported restaurant meals.
A: Iron and vitamin D repletion are on track and correspond with the reported energy change. Falling hs-CRP supports reduced inflammatory load. The bloating pattern points to a food trigger rather than a baseline motility issue, given its clustering with eating out.
P: Continue iron at the current 65 mg elemental daily and vitamin D at 2,000 IU daily. Begin structured reintroduction, one food group every four days, logged in the symptom tracker. Review the reintroduction log in four weeks. Recheck ferritin, vitamin D, and hs-CRP in eight weeks, at the sixteen-week mark of the protocol.
Composite scenario: session eight, anxiety with a sleep component.
S: Client reports two panic episodes since the last session, both at work and both in the afternoon. Describes the breathing technique as helpful in one and forgotten in the other. Reports sleep onset around 45 minutes, improved from 90. States they told a colleague about the anxiety for the first time.
O: GAD-7 score 11, down from 16 at intake. Panic episodes 2 this week, down from 5 per week at intake, per the client's episode log. Attended on time. Affect brighter than previous sessions. Engaged throughout the 50 minutes and initiated two topics.
A: Symptom load is decreasing on both measures, and the falling episode count tracks the client's own report. GAD-7 captures the generalized worry rather than the panic, so the episode log carries the primary outcome here. Disclosing to a colleague is a meaningful shift in the avoidance pattern that has been a treatment focus. The technique works when remembered, so the gap is cueing rather than skill.
P: Add a phone reminder at 2pm as a cue for the breathing practice. Continue weekly sessions. Introduce cognitive restructuring for workplace-specific thoughts next session. Re-administer GAD-7 and review the episode log in four weeks.
Composite scenario: visit five, three weeks into care following a rotator cuff strain.
S: Client reports shoulder pain 3 of 10 with overhead reaching, down from 7 of 10 at evaluation. Describes sleeping through the night for the first time in six weeks. Reports completing the home program 5 of 7 days.
O: Active shoulder flexion 155 degrees, up from 120 at evaluation. Abduction 140 degrees, up from 105. External rotation strength 4+ of 5, up from 3+ of 5. Negative empty can test. No pain with resisted internal rotation.
A: Range of motion and strength are improving on schedule at three weeks into care. The negative empty can test and the resolved night pain both indicate reduced irritability. Abduction remains the larger deficit at 140 degrees, with flexion closer to full at 155.
P: Progress the home program to resistance band external rotation, two sets of fifteen, daily. Add supine abduction work to target the larger deficit. Continue twice weekly for two weeks, then reassess for discharge. Re-measure flexion and abduction at the next visit.
Composite scenario: home visit, post-stroke, focused on kitchen independence.
S: Client reports wanting to make their own breakfast without help. Describes frustration with jar lids and the kettle. Spouse reports the client attempted breakfast twice this week unsupervised.
O: Completed a simulated breakfast task with minimal assistance for the kettle and moderate assistance for jar opening. Standing tolerance at the counter 8 minutes, up from 4 minutes two weeks ago. Left-hand grip 12 lb, up from 8 lb. No loss of balance during the task.
A: Standing tolerance and grip strength are both improving, and balance held throughout the task. The unsupervised attempts reported by the spouse involved boiling water at a standing tolerance of 8 minutes, which is a burn and fatigue risk this client is not yet ready to carry alone. Jar opening remains the limiting step, and it is a grip strength issue rather than a sequencing one.
P: Discussed kettle safety with the client and spouse today, and agreed that hot-water tasks stay supervised until standing tolerance reaches 15 minutes. Recommended a cordless kettle with an auto shut-off. Issue a jar opener and train its use next session. Continue the grip strengthening program, three times daily. Reassess standing tolerance and grip in two weeks.
Composite scenario: fourth session, chronic upper back tension.
S: Client reports upper back tension 4 of 10, down from 7 of 10 at the first session. Describes relief lasting about five days after the last treatment, up from two days. Reports a new desk setup at work. No new injuries.
O: Palpable hypertonicity in the upper trapezius bilaterally, reduced from the previous session. Right levator scapulae remains tender to moderate pressure. Cervical rotation visually symmetrical. Treated 60 minutes, supine and prone, moderate pressure.
A: Tension is reducing and the lengthening relief window suggests the change is holding between sessions. The new desk setup is the likely contributor. Right levator scapulae is now the primary remaining restriction.
P: Focus the next session on right levator scapulae and cervical attachments. Extend the interval from one week to ten days, double the current five-day relief window, to test whether the change holds. Give two self-care stretches for the right side. Reassess pressure tolerance and rotation at the next visit.
Composite scenario: visit six, lower back pain with a lifting mechanism.
S: Client reports lower back pain 2 of 10, down from 6 of 10 at the initial visit. Describes returning to the gym with lighter loads and no flare. Reports occasional morning stiffness lasting under ten minutes.
O: Lumbar flexion full and pain-free. Extension full with mild end-range discomfort. Straight leg raise negative bilaterally. Restriction noted at L4 to L5 on motion palpation, reduced from the previous visit. Adjustment delivered to the lumbar spine, side posture.
A: Symptoms and objective restriction are both resolving on the expected timeline. Return to the gym without a flare is a functional milestone. Brief morning stiffness at this stage is consistent with normal recovery rather than a setback.
P: Reduce visit frequency to once every two weeks. Continue the current core stability program and progress gym loads by ten percent weekly. Reassess at the next visit and plan discharge criteria if the pattern holds.
{{soap-note-template}}
Three things go in the assessment: what the subjective and objective data mean together, whether the client is progressing against their goals, and what you think is driving the pattern. It is the section that separates a useful note from a transcript, and it is the one that gets written as a summary of the two sections above it.
A test that works: cover the subjective and objective sections and read the assessment alone. If it still tells you something, it is doing its job.
Five errors recur across disciplines: interpretation placed in the subjective section, an assessment that restates the sections above it, plans without amounts or dates, copy-forward without editing, and detail that changes nothing you do.
Copying an example once saves you a session. Turning it into a template saves you every session after that.
Take the example closest to your discipline and strip it down to the scaffolding: the section headers, the prompts you want to answer each time, and the measurements you take at every visit. The dietitian example becomes weight, waist, a food record summary, and a glucose average. The physical therapy example becomes range of motion, strength grade, and the special tests you run for that body region.
Three rules keep a template useful:
A downloadable starting point sits at SOAP note template, and note templates covers building your own inside Practice Better.
You write the four sections in order, keeping each one to its own source of information. How to write a SOAP note walks through what belongs in each section and how to word it. The eight examples on this page show the finished result.
Long enough that another practitioner could pick up the client's care from it. For a routine follow-up that is often four to six lines per section. A first session, a significant change, or an adverse event earns more.
Many do. Dietitians often use ADIME instead, which reorganizes the same information around the nutrition care process. Health coaches working outside a clinical setting sometimes use a custom format. See ADIME versus SOAP notes for the comparison.
AI scribes draft the note from a session recording, and the practitioner reviews and edits it. Practice Better's AI Charting Assistant records, transcribes, and summarizes telehealth, Zoom, and in-person sessions, and outputs notes in SOAP, bullet points, or narrative. Clinical reasoning in the assessment section is the part that still needs you.
Practice Better supports SOAP, ADIME, DAP, BIRP, and custom note formats built from scratch. Pick the one your discipline and your referral network already read.
Copy the example closest to your discipline, cut what does not apply, and save it as a template so the structure is there before you start typing.
Practice Better's note templates let you build the format once and reuse it for every client interaction, and AI charting drafts the note from the session so you review rather than transcribe. Start a free trial of Practice Better to build your note templates and chart in the format your discipline uses.
{{free-trial-simple-text}}
Below are eight complete SOAP notes, one each for a dietitian, health coach, functional medicine practitioner, counselor, physical therapist, occupational therapist, massage therapist, and chiropractor. Each shows all four sections written out, so you can see how the same structure changes shape across disciplines.
Every example here is illustrative. The clients are composites written to demonstrate the format, and none is a real person or a real record.
For the mechanics of writing each section, see how to write a SOAP note. This page is the example set.
A SOAP note is a client record written in four sections, subjective, objective, assessment, and plan, where each section does a job the others do not.
| Section | The question it answers | Written by |
|---|---|---|
| Subjective | What did the client report? | The client, in their words |
| Objective | What did you measure or observe? | Your instruments and your eyes |
| Assessment | What does it mean? | Your clinical reasoning |
| Plan | What happens next? | You, with dates and amounts |
The failure that shows up in weak notes is the assessment restating the two sections above it. When that happens, three sections are doing one job and the note carries no reasoning.
Composite scenario: third visit, weight management and blood sugar goals.
S: Client reports sticking to the meal structure on weekdays and losing it on weekends. Describes strong afternoon cravings around 3pm, four or five days a week. Energy improved since the last visit. Sleeping 6 to 7 hours, up from 5. Reports no changes to medication.
O: Weight 186 lb, down 3 lb from 189 lb four weeks ago. Waist 38 in, down 1 in. Three-day food record shows average 1,650 kcal, protein averaging 62 g per day against the 100 g target. Fasting glucose log averages 112 mg/dL, down from 124 mg/dL.
A: Steady progress toward the weight goal at a safe rate. The afternoon craving pattern lines up with low protein at breakfast and lunch, averaging 20 g across both meals. Weekend structure is the main gap, and glucose is trending down in line with the weight change.
P: Raise breakfast protein to 30 g, with three specific options given. Add a mid-afternoon protein snack. Client to log weekends only for the next two weeks. Recheck weight, waist, and glucose log at the next visit in four weeks. Send the protein guide through the client portal today.
Composite scenario: week six of a twelve-week habit program.
S: Client reports the morning walk is now automatic and no longer needs a reminder. Describes the evening screen habit as unchanged. Reports one high-stress week at work and says the walk held through it, which surprised them.
O: Walk logged 6 of 7 days, up from 4 of 7 in week three. Screen-time entry blank for 5 of 7 days. Weekly check-in form completed on time. Self-rated stress 7 of 10, up from 5 of 10.
A: The walking habit is established, and holding it through a high-stress week is the strongest signal so far. The screen habit has no attachment point yet, which is why logging keeps lapsing. Rising stress is a risk to both.
P: Leave the walk alone and stop logging it. Attach the screen limit to an existing cue: phone on the charger in the kitchen when the dishwasher goes on. Add a two-minute wind-down to the evening check-in. Revisit stress at the next session in one week.
Composite scenario: follow-up after lab review, fatigue and digestive complaints.
S: Client reports fatigue improved from 8 of 10 to 5 of 10 since starting the protocol eight weeks ago. Bloating now occurs 2 days a week, down from daily. Reports one flare after a restaurant meal. Adherence to the elimination phase described as roughly 80 percent.
O: Ferritin 42 ng/mL, up from 18 ng/mL. Vitamin D 38 ng/mL, up from 22 ng/mL. hs-CRP 2.1 mg/L, down from 4.8 mg/L. Weight stable at 142 lb. Symptom tracker shows bloating clustered on days with reported restaurant meals.
A: Iron and vitamin D repletion are on track and correspond with the reported energy change. Falling hs-CRP supports reduced inflammatory load. The bloating pattern points to a food trigger rather than a baseline motility issue, given its clustering with eating out.
P: Continue iron at the current 65 mg elemental daily and vitamin D at 2,000 IU daily. Begin structured reintroduction, one food group every four days, logged in the symptom tracker. Review the reintroduction log in four weeks. Recheck ferritin, vitamin D, and hs-CRP in eight weeks, at the sixteen-week mark of the protocol.
Composite scenario: session eight, anxiety with a sleep component.
S: Client reports two panic episodes since the last session, both at work and both in the afternoon. Describes the breathing technique as helpful in one and forgotten in the other. Reports sleep onset around 45 minutes, improved from 90. States they told a colleague about the anxiety for the first time.
O: GAD-7 score 11, down from 16 at intake. Panic episodes 2 this week, down from 5 per week at intake, per the client's episode log. Attended on time. Affect brighter than previous sessions. Engaged throughout the 50 minutes and initiated two topics.
A: Symptom load is decreasing on both measures, and the falling episode count tracks the client's own report. GAD-7 captures the generalized worry rather than the panic, so the episode log carries the primary outcome here. Disclosing to a colleague is a meaningful shift in the avoidance pattern that has been a treatment focus. The technique works when remembered, so the gap is cueing rather than skill.
P: Add a phone reminder at 2pm as a cue for the breathing practice. Continue weekly sessions. Introduce cognitive restructuring for workplace-specific thoughts next session. Re-administer GAD-7 and review the episode log in four weeks.
Composite scenario: visit five, three weeks into care following a rotator cuff strain.
S: Client reports shoulder pain 3 of 10 with overhead reaching, down from 7 of 10 at evaluation. Describes sleeping through the night for the first time in six weeks. Reports completing the home program 5 of 7 days.
O: Active shoulder flexion 155 degrees, up from 120 at evaluation. Abduction 140 degrees, up from 105. External rotation strength 4+ of 5, up from 3+ of 5. Negative empty can test. No pain with resisted internal rotation.
A: Range of motion and strength are improving on schedule at three weeks into care. The negative empty can test and the resolved night pain both indicate reduced irritability. Abduction remains the larger deficit at 140 degrees, with flexion closer to full at 155.
P: Progress the home program to resistance band external rotation, two sets of fifteen, daily. Add supine abduction work to target the larger deficit. Continue twice weekly for two weeks, then reassess for discharge. Re-measure flexion and abduction at the next visit.
Composite scenario: home visit, post-stroke, focused on kitchen independence.
S: Client reports wanting to make their own breakfast without help. Describes frustration with jar lids and the kettle. Spouse reports the client attempted breakfast twice this week unsupervised.
O: Completed a simulated breakfast task with minimal assistance for the kettle and moderate assistance for jar opening. Standing tolerance at the counter 8 minutes, up from 4 minutes two weeks ago. Left-hand grip 12 lb, up from 8 lb. No loss of balance during the task.
A: Standing tolerance and grip strength are both improving, and balance held throughout the task. The unsupervised attempts reported by the spouse involved boiling water at a standing tolerance of 8 minutes, which is a burn and fatigue risk this client is not yet ready to carry alone. Jar opening remains the limiting step, and it is a grip strength issue rather than a sequencing one.
P: Discussed kettle safety with the client and spouse today, and agreed that hot-water tasks stay supervised until standing tolerance reaches 15 minutes. Recommended a cordless kettle with an auto shut-off. Issue a jar opener and train its use next session. Continue the grip strengthening program, three times daily. Reassess standing tolerance and grip in two weeks.
Composite scenario: fourth session, chronic upper back tension.
S: Client reports upper back tension 4 of 10, down from 7 of 10 at the first session. Describes relief lasting about five days after the last treatment, up from two days. Reports a new desk setup at work. No new injuries.
O: Palpable hypertonicity in the upper trapezius bilaterally, reduced from the previous session. Right levator scapulae remains tender to moderate pressure. Cervical rotation visually symmetrical. Treated 60 minutes, supine and prone, moderate pressure.
A: Tension is reducing and the lengthening relief window suggests the change is holding between sessions. The new desk setup is the likely contributor. Right levator scapulae is now the primary remaining restriction.
P: Focus the next session on right levator scapulae and cervical attachments. Extend the interval from one week to ten days, double the current five-day relief window, to test whether the change holds. Give two self-care stretches for the right side. Reassess pressure tolerance and rotation at the next visit.
Composite scenario: visit six, lower back pain with a lifting mechanism.
S: Client reports lower back pain 2 of 10, down from 6 of 10 at the initial visit. Describes returning to the gym with lighter loads and no flare. Reports occasional morning stiffness lasting under ten minutes.
O: Lumbar flexion full and pain-free. Extension full with mild end-range discomfort. Straight leg raise negative bilaterally. Restriction noted at L4 to L5 on motion palpation, reduced from the previous visit. Adjustment delivered to the lumbar spine, side posture.
A: Symptoms and objective restriction are both resolving on the expected timeline. Return to the gym without a flare is a functional milestone. Brief morning stiffness at this stage is consistent with normal recovery rather than a setback.
P: Reduce visit frequency to once every two weeks. Continue the current core stability program and progress gym loads by ten percent weekly. Reassess at the next visit and plan discharge criteria if the pattern holds.
{{soap-note-template}}
Three things go in the assessment: what the subjective and objective data mean together, whether the client is progressing against their goals, and what you think is driving the pattern. It is the section that separates a useful note from a transcript, and it is the one that gets written as a summary of the two sections above it.
A test that works: cover the subjective and objective sections and read the assessment alone. If it still tells you something, it is doing its job.
Five errors recur across disciplines: interpretation placed in the subjective section, an assessment that restates the sections above it, plans without amounts or dates, copy-forward without editing, and detail that changes nothing you do.
Copying an example once saves you a session. Turning it into a template saves you every session after that.
Take the example closest to your discipline and strip it down to the scaffolding: the section headers, the prompts you want to answer each time, and the measurements you take at every visit. The dietitian example becomes weight, waist, a food record summary, and a glucose average. The physical therapy example becomes range of motion, strength grade, and the special tests you run for that body region.
Three rules keep a template useful:
A downloadable starting point sits at SOAP note template, and note templates covers building your own inside Practice Better.
You write the four sections in order, keeping each one to its own source of information. How to write a SOAP note walks through what belongs in each section and how to word it. The eight examples on this page show the finished result.
Long enough that another practitioner could pick up the client's care from it. For a routine follow-up that is often four to six lines per section. A first session, a significant change, or an adverse event earns more.
Many do. Dietitians often use ADIME instead, which reorganizes the same information around the nutrition care process. Health coaches working outside a clinical setting sometimes use a custom format. See ADIME versus SOAP notes for the comparison.
AI scribes draft the note from a session recording, and the practitioner reviews and edits it. Practice Better's AI Charting Assistant records, transcribes, and summarizes telehealth, Zoom, and in-person sessions, and outputs notes in SOAP, bullet points, or narrative. Clinical reasoning in the assessment section is the part that still needs you.
Practice Better supports SOAP, ADIME, DAP, BIRP, and custom note formats built from scratch. Pick the one your discipline and your referral network already read.
Copy the example closest to your discipline, cut what does not apply, and save it as a template so the structure is there before you start typing.
Practice Better's note templates let you build the format once and reuse it for every client interaction, and AI charting drafts the note from the session so you review rather than transcribe. Start a free trial of Practice Better to build your note templates and chart in the format your discipline uses.
{{free-trial-simple-text}}
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