SOAP note generator, with a full example and template

A SOAP note is a widely used format for documenting a focused clinical visit: Subjective (what the patient reports), Objective (vital signs, examination and results), Assessment (the clinician's impression) and Plan (tests, treatment, advice and follow-up). This page pairs a full example and a copyable template with Scripta's SOAP note generator, which drafts one from a recorded visit.

Transcription and the draft note are usually ready within 1–3 minutes of pressing Stop; the note itself takes about 20–40 seconds.

Last updated Scripta by SyncEdge

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Scripta drafts documentation of what was said in the visit; the clinician reviews, edits and signs; it does not diagnose.

On this page

What goes in each section of a SOAP note?

Subjective holds what the patient tells you, Objective only what was measured or examined, Assessment only your own impression, and Plan the tests, treatment, advice and follow-up you gave. Keeping each fact in its own section is what makes a SOAP note quick to read.

Subjective
The chief complaint in the patient's words, and the history of the present illness: onset, duration, character, severity, what makes it worse or better, and associated symptoms. Relevant past history, current medicines and allergies, as reported during the visit.
Objective
Only findings stated aloud during the visit: vital signs, examination findings, and test or imaging results the clinician read out. Scripta never infers a finding that was not said.
Assessment
The clinician's own stated impression and differentials, in the clinician's words. Scripta never adds a diagnosis the clinician did not say.
Plan
Investigations ordered; medicines with name, dose, route, frequency and duration exactly as spoken; procedures; advice; referrals; and when to follow up, including what should bring the patient back sooner.

What does a SOAP note look like? A full outpatient example

Here is a complete SOAP note Scripta drafted from an invented first visit: a rice farmer with three days of burning epigastric pain after a week of mixed pills from a village shop and ibuprofen. The items under Please verify are what the doctor was asked to check.

SOAP noteFirst outpatient visit · burning epigastric painFictional patient for illustration

Subjective

Chief complaint: burning epigastric pain for 3 days.

  • Burning pain at the top of the stomach, under the ribs; worst on an empty stomach, eases a little after eating.
  • Nausea; vomited twice yesterday (water and rice), no blood or dark material.
  • Stools normal, not black.
  • Back pain from heavy work in the rice fields. Has taken mixed pills bought from a village shop for 1 week, one packet each time (4-5 pills per packet, yellow and white, identity unknown).
  • Ibuprofen 400 mg, one tablet each time when the pain is severe.
  • Drinks rice whisky with friends 2-3 times a week.
  • Hypertension, on amlodipine 5 mg once daily.
  • Allergies: once had an itchy rash after a medicine; cannot recall which.

Objective

  • BP 132/84 mmHg, pulse 88, temperature 37.1 °C
  • Epigastric tenderness
  • No right lower quadrant tenderness

Assessment

Gastritis, or possibly a stomach ulcer, from the mixed pills and ibuprofen.

Plan

  • Stop the mixed pills and ibuprofen.
  • Omeprazole 20 mg once daily before breakfast for 4 weeks.
  • Paracetamol 500 mg, 1 tablet every 6 hours as needed for back pain.
  • Advised to stop drinking alcohol.
  • Return to hospital immediately if vomiting blood, passing black stools or pain gets much worse.
  • Follow-up in 2 weeks.

Please verify (shown to the clinician, not part of the note)

  • How often the mixed pills and ibuprofen were taken was not stated ("one packet each time", "one tablet each time").
  • Contents of the mixed pills are unknown (4-5 pills per packet, yellow and white).
  • Allergy history incomplete: itchy rash after a medicine the patient cannot name.

The same visit, written as a full history and physical. The doctor also gave the patient a plain-language summary.

How should I talk during the visit so the SOAP note comes out right?

Say findings and decisions out loud. Scripta writes only what it hears, so a blood pressure you read silently or an impression you only thought will not be in the note; that section will say not discussed instead.

  • Read the vital signs and key examination findings aloud, even when they are on a monitor in front of you.
  • Put your impression into words before the plan: "I think this is gastritis, possibly an ulcer, from the painkillers."
  • Give each medicine in full: name, dose, how often and for how long. A missing part is kept as said and flagged, never filled in.
  • Ask about allergies and let the answer be heard, including "no known drug allergies".
  • End by summarising the plan and the warning signs to the patient. It is good practice, and it gives the note a clean Plan.
  • If the patient speaks a regional dialect, choose Thai as the spoken language instead of auto-detect.

How does Scripta turn a recorded visit into a SOAP note?

It transcribes the visit with speaker labels, then drafts the four sections from that transcript alone, following the section rules above. Anything it could not place with confidence goes into a Please verify list for you.

  1. 1

    Confirm consent and record

    Tick that the patient agreed, then record in the browser, or upload an audio or video file of the visit.

  2. 2

    Choose SOAP note

    Pick SOAP note as the AI note, and the language the note should be written in.

  3. 3

    Review the draft and its flags

    Check each section against what was said and resolve the Please verify items. Edit the text, or type an instruction to redraft it.

  4. 4

    Copy it into the chart

    Copy the whole note or one section as plain text and paste it into your HIS or EMR.

Doses, numbers, units and dates are copied as spoken; if one was unclear, what was said is kept and flagged. The note stays a draft until you have reviewed it.

Can the SOAP note be written in Thai?

Yes. The headings stay in English (Subjective, Objective, Assessment, Plan) and the body is written in Thai, with drug names, doses and abbreviations such as BP and mg in their usual form, the way Thai charts are written. You can also have the whole note in English.

When the patient speaks Isan or another regional dialect, the note is written in standard Thai. A dialect phrase that matters is quoted with its meaning, and one Scripta cannot read with confidence is flagged. In the Thai version of the example above, the patient's "มื้อละซอง" became one packet a day, with a flag asking the doctor to confirm it was not one packet per meal.

SOAP note or H&P: which one do I need?

Use a SOAP note for a focused visit about one or two problems, typically in outpatients. Use an H&P when the patient is new to you or being admitted, and you need the full history, review of systems and examination on record.

  • SOAP: four sections, a few lines each; the history covers what bears on today's problem.
  • H&P: ten sections, from chief complaint to plan, including past, family and social history and a review of systems.
  • The follow-up to either: a progress note, which starts from what changed since last time.

Copy the SOAP note template

Paste this outline into your HIS or EMR and fill each heading. The prompts under each heading are the rules Scripta follows when it drafts from a recording.

Plain text, ready to paste into your HIS or EMR
Subjective
Chief complaint (in the patient's words):
History of present illness (onset, duration, character, severity, what makes it better or worse, associated symptoms):
Relevant past history:
Current medicines:
Allergies (with the reaction, or "no known drug allergies"):

Objective
Vital signs (BP, HR, RR, temperature, SpO2, weight):
Examination findings:
Results read out today:

Assessment
Impression and differentials, in the clinician's words:

Plan
Investigations:
Medicines (name, dose, route, frequency, duration):
Procedures / referrals:
Advice, and when to come back sooner:
Follow-up:

Frequently asked questions

What is the difference between Subjective and Objective?

Subjective is what the patient tells you, such as "burning pain for three days, worse on an empty stomach". Objective is what you measure or examine yourself, such as a blood pressure of 132/84 or epigastric tenderness. If the patient says it, it is Subjective; if you found it, it is Objective.

How long should a SOAP note be?

As short as the visit allows. A focused outpatient SOAP note is usually a few lines per section: enough for a colleague to see what happened, what you think and what comes next without re-reading the whole consultation. Put detail in the section it belongs to rather than repeating it across sections.

Will the AI add findings or a diagnosis I didn't say?

It is instructed not to. The Objective section holds only findings stated aloud, the Assessment holds only the impression you gave, and a section with nothing to support it says "not discussed". Anything unclear goes into the Please verify list for you to check.

Is a free online SOAP note generator safe for patient data?

Check four things before you paste or upload a visit: whether the patient consented, who processes the data and in which country, how long it is kept, and whether you can delete it. Avoid pasting identifiers into anonymous tools. Scripta names its processors and lets you delete any visit at any time.

Can I use a SOAP note for a follow-up visit?

Yes, many clinicians do. Scripta also offers a progress note for follow-ups, with Interval History and Current Status in place of Subjective, and it can draft it from the previous visit's note when the visits are linked by HN. Either way, today's findings come only from today's conversation.

Do pharmacists, physiotherapists and nurses write SOAP notes too?

Yes. The four-part structure is the same across professions; what goes in each part differs, such as medication problems for pharmacists or movement assessment for physiotherapists. Scripta's SOAP template is written for doctors' outpatient visits, but any clinician can use it and edit the draft to suit their own charting.

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