SOAP Note Template

SOAP notes provide a structured way to organize clinical information, document assessment and reasoning, and connect identified problems with an appropriate plan.

The YourDNP SOAP Note Template is designed to help DNP-FNP students practice clinical documentation during coursework and clinical education. It provides prompts for the subjective, objective, assessment, and plan portions of a note while leaving enough flexibility to adapt the format to different patient encounters and program expectations.

The template is an educational resource. It does not replace your clinical site’s electronic health record, required documentation format, faculty instructions, or program-specific clinical documentation requirements.

What the SOAP Note Template Includes

The template provides space for:

• Encounter overview
• Chief concern
• History of present illness
• Relevant medical, surgical, family, and social history
• Medication and allergy review
• Focused review of systems
• Vital signs
• Focused physical examination
• Relevant diagnostic or laboratory findings
• Assessment by problem
• Differential diagnoses when appropriate
• Problem-linked plan
• Medications and treatment
• Diagnostic testing
• Patient education
• Follow-up
• Referral or escalation when indicated
• Student clinical reasoning
• Preceptor feedback
• Final documentation review

The format is intentionally broad enough to support different types of outpatient encounters without prescribing a single documentation style for every program or practice setting.

Organize the Note Around the Clinical Encounter

A SOAP note should reflect the information that is relevant to the patient’s presentation and the decisions being made during the encounter.

The template can help you organize that information, but every section does not need the same level of detail for every patient. A focused acute visit may require a different history and examination than a chronic-disease follow-up, preventive visit, or complex multi-problem encounter.

Use your clinical judgment, preceptor guidance, site expectations, and program requirements to determine what belongs in the note.

Protect Patient Privacy

Do not place patient names, dates of birth, medical-record numbers, addresses, photographs, or other identifying information into a downloaded YourDNP template unless its use has been specifically authorized within an appropriate clinical or educational system.

If you are using the template for coursework or clinical practice exercises, follow your program’s requirements for de-identification and your clinical site’s privacy and confidentiality policies.

Your official patient documentation belongs in the documentation system approved by the clinical site.

Download the SOAP Note Template

Blank Template

Use the blank template to practice organizing a clinical encounter and documenting the relationship between history, examination findings, assessment, and plan.

Completed Example

The completed example demonstrates how a fictional primary-care encounter might be organized using the template.

The patient, practice setting, findings, and encounter are fictional. The example is provided to demonstrate documentation structure and clinical reasoning and should not be interpreted as individualized medical advice or a treatment recommendation.

SOAP Note Structure

The four major components provide a basic framework for organizing a clinical note.

Subjective

The Subjective section contains information obtained from the patient, caregiver, or other history source.

Depending on the encounter, this may include the chief concern, history of present illness, relevant medical history, medications, allergies, family and social history, and review of systems.

The history should be focused enough to support the clinical question while still capturing information that could influence assessment or management.

Objective

The Objective section contains observable or measurable information from the encounter.

This may include vital signs, physical examination findings, point-of-care testing, laboratory results, imaging, or other diagnostic information relevant to the assessment.

Avoid filling the note with findings that do not contribute to the encounter simply to make the examination appear more comprehensive.

Assessment

The Assessment identifies the clinical problems being addressed and documents your interpretation of the available information.

Depending on the encounter and your program’s expectations, this may include:

• Primary diagnosis or working diagnosis
• Additional active problems
• Relevant differential diagnoses
• Clinical status of chronic conditions
• Risk factors or other findings that influence management

The assessment should be supported by the history, examination, and available diagnostic information documented earlier in the note.

Plan

The Plan describes what will be done for each identified problem.

Depending on the encounter, this may include treatment, medications, diagnostic testing, referrals, patient education, preventive care, follow-up, monitoring, and instructions for seeking additional or urgent care.

Organizing the plan by problem can make the relationship between the assessment and management decisions easier to follow.

Use the Template to Practice Clinical Reasoning

The student clinical-reasoning section in the YourDNP template is separate from the traditional SOAP structure.

It provides additional space to work through questions such as:

• Which findings most influenced the assessment?
• Which diagnoses were considered?
• Why were particular diagnoses more or less likely?
• What information influenced the management plan?
• What would change the plan or require escalation?
• What questions remain for the preceptor?

This section is intended for learning and reflection. It may not belong in an official patient record unless required or permitted by the clinical site.

Use It With the Clinical Rotation Resources

The Clinical Rotation Guide covers broader clinical-learning topics, including preparation, working with a preceptor, patient presentations, documentation, feedback, and making each rotation useful.

→ Explore the Clinical Rotation Guide

For additional support with assessment, differential diagnosis, follow-up, escalation, and documentation of clinical reasoning:

→ Explore FNP Clinical Pearls

You can also use the Clinical Rotation Planner to organize goals, schedules, learning experiences, and feedback throughout a rotation.

→ Use the Clinical Rotation Planner

Adapt the Template to Your Program and Clinical Site

SOAP documentation conventions vary across academic programs, specialties, clinical settings, preceptors, and electronic health record systems.

Use the template as a structured starting point, then adapt it to the requirements that apply to your clinical experience. Your program, faculty, preceptor, and clinical site remain the appropriate sources for determining what documentation is required.

A useful SOAP note should show how the information gathered during the encounter led to the assessment and how that assessment shaped the plan.

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