This page is the bare form for any clinical visit. The headings stay the same in every specialty. What changes is the detail: a primary care note fills Objective with vital signs and an exam, a therapy note fills it with mental status observations. The example below is a general medical visit. For a therapy‑specific version with a session example, use the SOAP note template for therapists.
Which SOAP variant to use
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Blank SOAP note (this page) | Any visit, when you want an empty form with prompts |
| Therapy and counseling sessions, with a worked session example |
| Medication management visits |
SOAP with a separate HPI and ROS | New problems in primary or urgent care, where the history needs more room |
| Clinics that put Assessment and Plan first so readers see the conclusion at the top; same four sections, different order |
What to write under each heading
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| Chief complaint in the patient's words. Onset, location, duration, character, severity, what makes it better or worse. Relevant history, medications, allergies |
| Vital signs. Exam findings by system. Test results with dates. Anything you measured or observed yourself |
| Diagnosis or differential, with the reasoning that links S and O to it. ICD-10-CM code for each problem |
| Treatment, tests ordered, referrals, patient education, return precautions, follow-up date |
Filled-in SOAP note example: acute low back pain
Dennis is a fictional 47‑year‑old warehouse worker seen in a primary care clinic. All details are invented for illustration.
S: "My lower back locked up lifting a box." Pain started 5 days ago while lifting at work, across the low back, worse on the right. Rates it 6 out of 10, worse bending and after sitting more than 30 minutes, eased by walking and ibuprofen. No pain down either leg. No numbness, weakness, or change in bladder or bowel control. No fever. No history of cancer. First episode. Takes no regular medications. No known drug allergies.
O: BP 128/80, pulse 76, temperature 36.8 C. Walks without a limp. Tender over the right lumbar paraspinal muscles, no midline tenderness. Forward flexion limited by pain. Straight leg raise negative both sides. Strength 5 out of 5 in both legs. Reflexes symmetric. Light touch sensation intact, including the saddle area.
A: Acute low back pain without sciatica or red flags, M54.50 (low back pain, unspecified). Mechanical pattern after lifting. No signs of nerve root involvement.
P: No imaging needed at this stage. Continue ibuprofen with food as needed, heat, and staying active within comfort. Light duty note for one week, no lifting over 10 kg. Handout on back exercises. Return at once for leg weakness, numbness in the groin or buttocks, or loss of bladder or bowel control. Follow up in 2 weeks if not improving.
Blank SOAP note template
Copy the lines below into your EHR or a document. To print it, paste it into a word processor and leave a few blank lines under each heading.
Patient: Date of birth: Date of visit: Clinician:
S (Subjective): Chief complaint. History of present illness. Pertinent history. Current medications. Allergies.
O (Objective): Vital signs. Examination findings. Results reviewed, with dates.
A (Assessment): Diagnosis or differential. ICD‑10‑CM code. Reasoning.
P (Plan): Treatment. Tests. Referrals. Education given. When to return. Next visit.
Signature, credentials, date and time:
Coding the example: why M54.50 and not M54.5
M54.5, low back pain, is a header code in the FY2027 ICD‑10‑CM and can't be billed on its own. It splits into M54.50 (unspecified), M54.51 (vertebrogenic low back pain) and M54.59 (other low back pain). The Alphabetic Index sends lumbago to M54.50, and lumbago with sciatica to M54.4‑ instead.
M54.5 also carries an Excludes1 note for low back strain, which is an injury code (S39.012‑). If Dennis's assessment had said "lumbar strain" rather than "low back pain," the code would come from that injury category instead. The words in your Assessment decide the code, so pick them on purpose. The M54.5 code page has more on the subcodes.
Common mistakes when filling in a blank SOAP note
- Recording the patient's own report in O. "Patient says pain is 6 out of 10" is Subjective, even though it's a number.
- Writing "negative" without saying for what. List the red flags you asked about, as in the example.
- An Assessment that only restates the complaint. Say what you think is going on and why.
- A Plan with no return precautions or follow-up date.
- Leaving blank headings in the final note. If a section genuinely has nothing, write why.
Correcting a SOAP note after it's signed
Mistakes happen, and the fix is an amendment, never an erasure. Medicare's documentation rules say the date and author of any amendment, correction or delayed entry should be identifiable, and the change clearly and permanently marked. On paper that means a single line through the error, so the original stays readable. Medicare fraud reviewers treat white‑out and blacked‑out sections as possible signs of alteration (Medicare Program Integrity Manual, chapter 3, section 3.3.2.5). In an EHR, use the addendum function rather than reopening and overwriting the note.
Because a SOAP note is part of the medical record, patients can request a copy under HIPAA (45 CFR 164.524). Write it in words you'd be comfortable having them read.
Filling SOAP notes with Twofold
Twofold records a visit and drafts it in SOAP order for you to edit. Its built‑in SOAP template is set up for mental health sessions; the University guide How to Write a SOAP Note From a Live Session shows the steps.
SOAP note template, psychiatric SOAP note template, HPI template, ROS template, physical exam checklist template and patient notes template.
Reviewed and updated October 2026.
