Best Free SOAP Note Templates 2025

Professional SOAP note templates for healthcare professionals. Download PDF, copy, and customize these comprehensive documentation templates for mental health, physical therapy, nursing, and primary care. Save 30 minutes per note with structured templates.

Try First 20 Notes FreeBrowse Templates

Why Use SOAP Note Templates?

Save Time

Reduce documentation time from 30 minutes to 5 minutes per note

Support Documentation Standards

Templates include commonly required elements to help meet documentation standards

Improve Quality

Standardized format ensures comprehensive and consistent documentation

Reduce Burnout

Spend less time on paperwork, more time with patients and family

Upgrade to AI-Powered SOAP Notes

While templates are helpful, AI can generate personalized, compliant SOAP notes from your shorthand in minutes.

HIPAA-compliant AI assistant
Voice dictation and AI scribe
15+ healthcare specialties
Auto-generated ICD-10 codes
Try First 20 Notes Free

How to Use These SOAP Note Templates

Follow these simple steps to customize our templates for your practice

1

Choose Your Specialty

Select the template that matches your healthcare specialty and practice type

2

Copy or Download

Use Copy, Download PDF, or Download TXT buttons to get the template

3

Customize for Your Practice

Replace the bracketed fields with your specific practice requirements

4

Save & Share

Save your customized template and share with colleagues using the direct link button

Template Action Buttons Guide

Copy Template

Copies the entire template to your clipboard for pasting into your EMR or word processor

Download .txt

Downloads the template as a plain text file that you can open in any text editor

Download PDF

Downloads a professionally formatted PDF that's ready to print or store in your files

Direct Link

Copies the page URL to share with colleagues or bookmark for easy access later

Professional SOAP Note Templates

Copy, download, and customize these templates for your practice

Quick Navigation

Mental Health
General Mental Health
Physical Therapy
Physical Therapy Evaluation
Nursing
Nursing
Primary Care
Primary Care Office
Nurse Practitioner
Nurse Practitioner
Massage Therapy
Massage Therapy
Veterinary
Veterinary
Psychiatry
Psychiatric Evaluation
Occupational Therapy
Occupational Therapy
Podiatry
Podiatric
Chiropractic
Chiropractic
Speech-Language Pathology
Speech-Language Pathology
Mental Health

General Mental Health Template

Versatile template for therapy sessions, psychiatric evaluations, and mental health follow-ups

Mental HealthTherapyPsychiatry
SOAP Note Template - Mental Health
SUBJECTIVE:
Chief complaint: [Patient's primary concern in their own words]
History of present illness: [Onset, duration, triggers, current symptoms]
Mental status: [Mood, affect, sleep, appetite, energy, concentration]
Risk assessment: [Suicidal/homicidal ideation, self-harm behaviors]
Substance use: [Current use, history, impact on symptoms]
Medication compliance: [Current medications, adherence, side effects]
Psychosocial stressors: [Work, relationships, financial, housing]
OBJECTIVE:
Appearance: [Grooming, dress, eye contact]
Behavior: [Cooperation, psychomotor activity, speech]
Mood/Affect: [Observed mood, range, appropriateness]
Thought process: [Organization, coherence, goal-directed]
Thought content: [Delusions, obsessions, phobias]
Perceptual disturbances: [Hallucinations, illusions]
Cognitive function: [Orientation, memory, concentration]
Insight/Judgment: [Level of awareness, decision-making capacity]
Assessment scores: [PHQ-9, GAD-7, PCL-5, etc.]
ASSESSMENT:
Primary diagnosis: [DSM-5 code and description]
Secondary diagnoses: [Comorbid conditions]
Severity: [Mild, moderate, severe]
Risk level: [Low, medium, high for safety concerns]
Treatment response: [Progress since last visit]
PLAN:
1. Treatment interventions: [Therapy type, techniques, frequency]
2. Medication management: [Changes, monitoring, side effects]
3. Safety planning: [Crisis contacts, coping strategies]
4. Referrals: [Psychiatrist, specialist, case management]
5. Follow-up: [Next appointment, frequency, goals]
6. Patient education: [Resources, homework, skills practice]
Physical Therapy

Physical Therapy Evaluation Template

Comprehensive template for PT initial evaluations and progress notes

Physical TherapyRehabilitationOrthopedic
SOAP Note Template - Physical Therapy
SUBJECTIVE:
Chief complaint: [Patient's description of problem]
Mechanism of injury: [How injury occurred, date]
Pain level: [0-10 scale, location, quality, aggravating/relieving factors]
Functional limitations: [Activities affected, work/sport participation]
Prior interventions: [Previous therapy, medications, surgery]
Goals: [Patient's desired outcomes]
Medical history: [Relevant past medical history, surgeries]
OBJECTIVE:
Observation: [Posture, gait, assistive devices, deformity]
Palpation: [Tenderness, swelling, temperature, muscle spasm]
Range of motion: [Active/passive ROM measurements]
Strength testing: [Manual muscle testing grades]
Special tests: [Orthopedic tests, positive/negative findings]
Neurological: [Reflexes, sensation, neural tension tests]
Functional assessment: [Transfers, balance, endurance]
Measurements: [Circumference, length, posture analysis]
ASSESSMENT:
Primary impairments: [Key physical limitations identified]
Functional diagnosis: [Movement dysfunction, activity limitations]
Prognosis: [Expected outcomes, timeline for recovery]
Rehab potential: [Good, fair, poor with rationale]
Safety concerns: [Fall risk, precautions needed]
PLAN:
1. Treatment frequency: [Times per week, duration]
2. Interventions: [Manual therapy, exercises, modalities]
3. Short-term goals: [2-4 weeks, specific, measurable]
4. Long-term goals: [Discharge goals, functional outcomes]
5. Patient education: [Home exercise program, precautions]
6. Equipment needs: [Assistive devices, orthotic recommendations]
7. Reassessment: [Timeline for progress evaluation]
Nursing

Nursing Assessment Template

Standard nursing template for patient assessments and shift notes

NursingPatient CareAssessment
SOAP Note Template - Nursing
SUBJECTIVE:
Chief complaint: [Patient's stated concern or reason for visit]
Pain assessment: [Location, intensity 0-10, quality, onset, duration]
Review of systems: [Respiratory, cardiac, GI, GU, neurological symptoms]
Medication compliance: [Adherence, side effects, effectiveness]
Activities of daily living: [Mobility, self-care, nutrition]
Psychosocial: [Mood, anxiety, support system, coping]
Patient understanding: [Disease process, treatment plan]
OBJECTIVE:
Vital signs: [Temperature, BP, HR, RR, O2 sat, pain scale]
General appearance: [Alert, oriented, distress level]
Skin: [Color, temperature, turgor, wounds, rashes]
Cardiovascular: [Heart sounds, peripheral pulses, edema]
Respiratory: [Breath sounds, effort, use of accessory muscles]
Gastrointestinal: [Bowel sounds, abdomen, last BM]
Genitourinary: [Urine output, catheter status, continence]
Neurological: [Level of consciousness, orientation, motor/sensory]
Musculoskeletal: [Mobility, strength, range of motion]
Laboratory values: [Recent labs, diagnostic results]
ASSESSMENT:
Primary nursing diagnoses: [NANDA-I approved diagnoses]
Priority problems: [Most urgent patient needs]
Risk factors: [Fall risk, infection risk, pressure ulcer risk]
Patient response: [To current interventions and treatments]
Progress toward goals: [Meeting, not meeting established outcomes]
PLAN:
1. Nursing interventions: [Specific actions to address diagnoses]
2. Medication administration: [Scheduled and PRN medications]
3. Monitoring: [Vital signs frequency, assessment parameters]
4. Patient education: [Disease management, self-care, safety]
5. Discharge planning: [Home care needs, follow-up appointments]
6. Collaboration: [Communication with physicians, other disciplines]
7. Reassessment: [Frequency of evaluation, outcome measures]
Primary Care

Primary Care Office Visit Template

General template for routine office visits and chronic disease management

Primary CareFamily MedicineChronic Disease
SOAP Note Template - Primary Care
SUBJECTIVE:
Chief complaint: [Patient's primary concern for today's visit]
History of present illness: [Onset, duration, associated symptoms, treatments tried]
Review of systems: [Systematic review of body systems]
Past medical history: [Significant illnesses, surgeries, hospitalizations]
Medications: [Current medications, dosages, adherence, side effects]
Allergies: [Drug allergies, environmental allergies, reactions]
Social history: [Smoking, alcohol, drugs, occupation, travel]
Family history: [Significant family medical history]
OBJECTIVE:
Vital signs: [Height, weight, BMI, BP, HR, RR, temperature]
General appearance: [Well-appearing, acute distress, development]
HEENT: [Head, eyes, ears, nose, throat examination]
Cardiovascular: [Heart rate, rhythm, murmurs, peripheral pulses]
Respiratory: [Breath sounds, respiratory effort, chest expansion]
Abdominal: [Bowel sounds, tenderness, organomegaly, masses]
Extremities: [Edema, cyanosis, clubbing, range of motion]
Neurological: [Mental status, cranial nerves, motor, sensory, reflexes]
Skin: [Lesions, rashes, color, temperature, turgor]
Laboratory: [Recent lab results, diagnostic tests]
ASSESSMENT:
Primary diagnosis: [ICD-10 code and description]
Secondary diagnoses: [Additional conditions being managed]
Differential diagnosis: [Other conditions considered]
Severity assessment: [Mild, moderate, severe]
Stability: [Stable, improving, worsening]
PLAN:
1. Diagnostic: [Laboratory tests, imaging, referrals ordered]
2. Therapeutic: [Medications prescribed, dosing, duration]
3. Monitoring: [Follow-up labs, vital signs, symptom tracking]
4. Lifestyle modifications: [Diet, exercise, smoking cessation]
5. Patient education: [Disease information, medication instructions]
6. Preventive care: [Screenings due, vaccinations needed]
7. Follow-up: [Return visit timing, specific parameters to monitor]
Nurse Practitioner

Nurse Practitioner Visit Template

Comprehensive template for NP evaluations, follow-ups, and chronic care management

Nurse PractitionerPrimary CareComprehensive Care
SOAP Note Template - Nurse Practitioner
SUBJECTIVE:
Chief complaint: [Patient's main concern today]
HPI: [History of present illness - OLDCARTS format]
Current medications: [Name, dose, frequency, adherence]
Allergies: [Drug, food, environmental with reactions]
PMH: [Past medical history, surgeries, hospitalizations]
Family history: [Relevant hereditary conditions]
Social history: [Tobacco, alcohol, drugs, occupation, exercise]
Review of systems: [Constitutional, HEENT, CV, Resp, GI, GU, MS, Neuro, Psych, Endo, Heme, Skin]
OBJECTIVE:
Vital signs: [BP, HR, RR, Temp, O2 sat, pain scale, BMI]
General: [Well-appearing, alert, cooperative, distress level]
Physical examination by systems:
HEENT: [Head, eyes, ears, nose, throat findings]
Cardiovascular: [Heart sounds, murmurs, peripheral pulses, edema]
Respiratory: [Breath sounds, effort, chest wall movement]
Abdominal: [Bowel sounds, tenderness, masses, hepatosplenomegaly]
Musculoskeletal: [Range of motion, strength, deformities]
Neurological: [Mental status, cranial nerves, motor, sensory, reflexes]
Skin: [Color, texture, lesions, wounds]
Diagnostic results: [Recent labs, imaging, other tests]
ASSESSMENT:
Primary diagnosis: [ICD-10 code and clinical description]
Secondary diagnoses: [Additional active problems]
Problem list updates: [Resolved, new, or modified problems]
Risk stratification: [Low, moderate, high risk factors]
Clinical decision making: [Rationale for diagnosis and treatment choices]
PLAN:
1. Medications: [New prescriptions, changes, discontinuations]
2. Diagnostic tests: [Labs, imaging, referrals ordered with rationale]
3. Therapeutic interventions: [Procedures, treatments, therapies]
4. Monitoring: [Parameters to track, frequency of monitoring]
5. Patient education: [Disease management, lifestyle modifications, warning signs]
6. Preventive care: [Screenings, vaccinations, health maintenance]
7. Follow-up: [Next visit timing, conditions requiring earlier return]
8. Care coordination: [Referrals, consultations, team communication]
Massage Therapy

Massage Therapy Assessment Template

Template for massage therapy evaluations and treatment notes

Massage TherapyBodyworkWellness
SOAP Note Template - Massage Therapy
SUBJECTIVE:
Chief complaint: [Primary reason for massage therapy]
Pain/discomfort: [Location, intensity 1-10, quality, onset, duration]
Aggravating factors: [Activities or positions that worsen symptoms]
Relieving factors: [What helps reduce pain/tension]
Previous massage experience: [Frequency, types, effectiveness]
Current stress levels: [Work, personal, physical stress factors]
Sleep quality: [Hours, quality, position preferences]
Exercise/activity level: [Type, frequency, recent changes]
Medical history: [Relevant conditions, surgeries, medications]
Goals for session: [Client's desired outcomes]
OBJECTIVE:
Posture assessment: [Standing, sitting alignment observations]
Palpation findings: [Muscle tension, trigger points, restrictions]
Range of motion: [Active and passive ROM limitations]
Skin condition: [Temperature, texture, color, lesions]
Muscle tone: [Hypertonic, hypotonic areas identified]
Breathing pattern: [Depth, rhythm, accessory muscle use]
Areas of restriction: [Fascial restrictions, adhesions]
Previous session response: [How client responded to last treatment]
ASSESSMENT:
Primary areas of concern: [Key regions requiring attention]
Muscle imbalances: [Overactive/underactive muscle groups]
Postural deviations: [Forward head, rounded shoulders, etc.]
Stress patterns: [Physical manifestations of stress/tension]
Treatment tolerance: [Client's ability to handle pressure/techniques]
Progress from previous sessions: [Improvements or changes noted]
PLAN:
1. Massage techniques: [Swedish, deep tissue, trigger point, etc.]
2. Focus areas: [Specific regions to address during session]
3. Pressure preference: [Light, moderate, firm based on tolerance]
4. Session duration: [Time allocation for different body regions]
5. Home care recommendations: [Stretches, self-massage, heat/ice]
6. Lifestyle modifications: [Ergonomic advice, stress management]
7. Follow-up frequency: [Recommended interval between sessions]
8. Contraindications noted: [Areas to avoid or modify technique]
Veterinary

Veterinary Examination Template

Comprehensive template for veterinary patient examinations and treatments

VeterinaryAnimal HealthPet Care
SOAP Note Template - Veterinary Medicine
SUBJECTIVE:
Chief complaint: [Owner's primary concern]
History of present illness: [Onset, duration, progression of symptoms]
Appetite: [Normal, decreased, increased, food preferences]
Water consumption: [Normal, increased, decreased]
Urination/defecation: [Frequency, consistency, color, straining]
Activity level: [Normal, lethargic, hyperactive, exercise tolerance]
Behavior changes: [Mood, social interaction, sleeping patterns]
Previous treatments: [Medications given, response to treatment]
Vaccination history: [Current status, due dates]
Travel history: [Recent trips, exposure to other animals]
OBJECTIVE:
Vital signs: [Temperature, heart rate, respiratory rate, weight]
Body condition score: [1-9 scale assessment]
Mentation: [Alert, responsive, depressed, obtunded]
Hydration status: [Normal, mild/moderate/severe dehydration]
Physical examination:
Head/neck: [Eyes, ears, nose, mouth, throat, lymph nodes]
Cardiovascular: [Heart sounds, pulse quality, mucous membranes]
Respiratory: [Breath sounds, effort, nasal discharge]
Abdominal: [Palpation findings, distension, pain]
Musculoskeletal: [Gait, range of motion, pain response]
Neurological: [Reflexes, coordination, mental status]
Integumentary: [Skin, coat condition, lesions, parasites]
ASSESSMENT:
Primary diagnosis: [Most likely condition based on findings]
Differential diagnoses: [Other conditions to consider]
Secondary conditions: [Concurrent health issues]
Body system assessment: [Which systems are affected]
Prognosis: [Excellent, good, fair, poor, grave]
PLAN:
1. Diagnostic tests: [Blood work, imaging, cultures, biopsies]
2. Treatment: [Medications, dosages, administration instructions]
3. Monitoring: [Parameters to watch, frequency of rechecks]
4. Client education: [Home care instructions, warning signs]
5. Follow-up: [Recheck appointments, call-back timeline]
6. Preventive care: [Vaccines, parasite prevention, dental care]
7. Referrals: [Specialist consultations if needed]
8. Prognosis discussion: [Expected outcomes, timeline for improvement]
Psychiatry

Psychiatric Evaluation Template

Comprehensive template for psychiatric evaluations, medication management, and mental health assessments

PsychiatryMental HealthMedication Management
SOAP Note Template - Psychiatry
SUBJECTIVE:
Chief complaint: [Patient's primary psychiatric concern]
History of present illness: [Onset, duration, triggers, severity, course]
Mental status changes: [Mood, behavior, cognition, sleep, appetite]
Psychiatric history: [Previous episodes, hospitalizations, treatments]
Current medications: [Psychiatric medications, compliance, effectiveness]
Substance use history: [Alcohol, drugs, tobacco use patterns]
Family psychiatric history: [Genetic predisposition, family mental health]
Psychosocial stressors: [Work, relationships, housing, financial]
Risk assessment: [Suicidal ideation, homicidal ideation, self-harm]
Functional impairment: [Work, social, activities of daily living]
OBJECTIVE:
Appearance: [Grooming, dress, hygiene, age-appropriate]
Behavior: [Cooperation, agitation, psychomotor activity]
Speech: [Rate, volume, tone, coherence, spontaneity]
Mood: [Patient's stated mood and observed affect]
Affect: [Range, intensity, appropriateness, stability]
Thought process: [Organization, logic, goal-directed, tangential]
Thought content: [Delusions, obsessions, compulsions, phobias]
Perceptions: [Hallucinations, illusions, depersonalization]
Cognitive function: [Orientation, memory, attention, concentration]
Insight: [Awareness of illness, need for treatment]
Judgment: [Decision-making capacity, safety awareness]
Assessment scales: [PHQ-9, GAD-7, MMSE, other relevant scales]
ASSESSMENT:
Primary psychiatric diagnosis: [DSM-5 diagnosis with code]
Secondary diagnoses: [Comorbid psychiatric conditions]
Medical comorbidities: [Relevant medical conditions]
Severity specifiers: [Mild, moderate, severe, with features]
Risk level: [Low, moderate, high for self-harm/suicide]
Functional impairment level: [Mild, moderate, severe]
Response to treatment: [Improving, stable, worsening]
PLAN:
1. Medication management: [Prescriptions, dosing, monitoring]
2. Psychotherapy: [Type, frequency, provider]
3. Safety planning: [Crisis intervention, emergency contacts]
4. Monitoring: [Vital signs, labs, side effects, efficacy]
5. Follow-up: [Appointment frequency, parameters to track]
6. Referrals: [Specialists, case management, social services]
7. Patient education: [Medication compliance, symptom monitoring]
8. Lifestyle interventions: [Sleep hygiene, exercise, stress management]
Occupational Therapy

Occupational Therapy Assessment Template

Comprehensive template for OT evaluations, treatment planning, and progress documentation

Occupational TherapyRehabilitationADL Assessment
SOAP Note Template - Occupational Therapy
SUBJECTIVE:
Chief complaint: [Patient's primary functional concern]
Occupational history: [Work, hobbies, daily routines, roles]
Functional limitations: [Self-care, work tasks, leisure activities]
Pain/discomfort: [Location, intensity 0-10, impact on function]
Goals: [Patient's desired functional outcomes]
Environmental factors: [Home, work, community barriers]
Social supports: [Family, caregivers, community resources]
Prior interventions: [Previous OT, therapy, adaptive equipment]
Medical history: [Relevant conditions, surgeries, medications]
Cognitive concerns: [Memory, attention, problem-solving]
OBJECTIVE:
Observation: [Posture, positioning, use of adaptive equipment]
Range of motion: [Active/passive ROM, joint mobility]
Strength: [Manual muscle testing, grip strength, endurance]
Coordination: [Fine motor, gross motor, bilateral coordination]
Sensation: [Light touch, proprioception, stereognosis]
Cognitive assessment: [Attention, memory, executive function]
Perceptual skills: [Visual perception, spatial awareness]
Activities of daily living: [Self-care task performance]
Instrumental ADLs: [Cooking, cleaning, money management]
Work/school tasks: [Job-specific or academic skill assessment]
Assistive technology: [Current use, effectiveness, needs]
ASSESSMENT:
Primary occupational performance issues: [Key functional deficits]
Occupational performance areas affected: [ADLs, IADLs, work, leisure]
Client factors impacting function: [Strength, ROM, cognition, etc.]
Environmental barriers: [Physical, social, cultural obstacles]
Rehabilitation potential: [Excellent, good, fair, poor]
Safety concerns: [Home safety, fall risk, injury prevention]
Readiness for discharge: [Current level, goals for d/c]
PLAN:
1. Treatment frequency: [Sessions per week, duration of care]
2. Intervention approach: [Remediation, compensation, adaptation]
3. Therapeutic activities: [Specific interventions planned]
4. Short-term goals: [2-4 weeks, measurable outcomes]
5. Long-term goals: [Discharge goals, functional outcomes]
6. Adaptive equipment: [Recommendations, training needed]
7. Environmental modifications: [Home, work, community changes]
8. Caregiver training: [Family education, support strategies]
9. Community resources: [Referrals, support groups, services]
10. Reassessment: [Timeline for progress evaluation]
Podiatry

Podiatric Examination Template

Specialized template for podiatric evaluations, foot care, and lower extremity assessments

PodiatryFoot CareLower Extremity
SOAP Note Template - Podiatry
SUBJECTIVE:
Chief complaint: [Primary foot/ankle concern]
History of present illness: [Onset, duration, location, aggravating factors]
Pain assessment: [Location, intensity 0-10, quality, timing]
Functional impact: [Walking, standing, sports, work activities]
Footwear history: [Type, fit, changes, orthotic use]
Activity level: [Exercise, sports, occupational demands]
Previous treatments: [Medications, therapies, surgeries]
Medical history: [Diabetes, vascular disease, arthritis]
Family history: [Foot problems, diabetes, arthritis]
Social history: [Occupation, lifestyle, activity goals]
OBJECTIVE:
Vital signs: [Blood pressure, pulse, temperature if indicated]
General inspection: [Gait, weight-bearing, assistive devices]
Bilateral foot examination:
Skin: [Color, temperature, texture, lesions, wounds]
Nails: [Shape, color, thickness, ingrown, fungal]
Structural: [Deformities, alignment, arch height]
Joints: [Range of motion, swelling, crepitus]
Muscles: [Strength, tone, atrophy]
Sensation: [Light touch, vibration, position sense]
Circulation: [Pulses, capillary refill, edema]
Biomechanical assessment: [Foot function, pressure points]
Footwear evaluation: [Fit, wear patterns, appropriateness]
Diagnostic tests: [X-rays, lab results, vascular studies]
ASSESSMENT:
Primary diagnosis: [ICD-10 code and description]
Secondary diagnoses: [Additional foot/ankle conditions]
Biomechanical factors: [Structural abnormalities, function]
Risk factors: [Diabetes, vascular disease, infection]
Functional limitations: [Impact on mobility, activities]
Prognosis: [Expected outcomes, timeline for healing]
Complications: [Infection risk, healing potential]
PLAN:
1. Treatment interventions: [Debridement, procedures, wound care]
2. Medications: [Topical, oral, injections as appropriate]
3. Orthotic devices: [Custom orthotics, padding, bracing]
4. Footwear recommendations: [Appropriate shoes, modifications]
5. Patient education: [Foot care, prevention, warning signs]
6. Activity modifications: [Restrictions, gradual return]
7. Follow-up care: [Frequency, monitoring parameters]
8. Referrals: [Specialists, ancillary services, imaging]
9. Preventive measures: [Diabetic foot care, nail care]
10. Home care instructions: [Wound care, exercises, precautions]
Chiropractic

Chiropractic Examination Template

Comprehensive template for chiropractic evaluations, spinal assessments, and treatment planning

ChiropracticSpinal HealthMusculoskeletal
SOAP Note Template - Chiropractic
SUBJECTIVE:
Chief complaint: [Primary musculoskeletal concern]
History of present illness: [Onset, mechanism, duration, progression]
Pain characteristics: [Location, intensity 0-10, quality, radiation]
Aggravating factors: [Positions, activities, movements]
Relieving factors: [Rest, positions, treatments, medications]
Functional limitations: [Work, sports, daily activities affected]
Previous treatments: [Chiropractic, medical, physical therapy]
Trauma history: [Accidents, falls, sports injuries]
Occupational factors: [Job demands, ergonomics, repetitive motions]
Exercise/activity level: [Current fitness, sports participation]
Sleep quality: [Position, comfort, morning stiffness]
Medical history: [Surgeries, medications, systemic conditions]
OBJECTIVE:
Postural analysis: [Standing, sitting alignment observations]
Gait assessment: [Walking pattern, asymmetries, compensations]
Spinal examination:
Inspection: [Alignment, muscle development, skin changes]
Palpation: [Tenderness, muscle spasm, joint restrictions]
Range of motion: [Cervical, thoracic, lumbar mobility]
Orthopedic tests: [Specific tests for region of complaint]
Neurological: [Reflexes, sensation, motor function]
Extremity examination: [As related to chief complaint]
Muscle strength testing: [Manual muscle testing grades]
Joint motion assessment: [Hypomobility, hypermobility]
Diagnostic imaging: [X-ray findings, MRI results if available]
ASSESSMENT:
Primary diagnosis: [ICD-10 code and chiropractic diagnosis]
Secondary diagnoses: [Additional musculoskeletal findings]
Subluxation complex: [Spinal segments involved]
Functional limitations: [Activities of daily living affected]
Biomechanical factors: [Postural, structural, movement patterns]
Risk factors: [Occupational, lifestyle, ergonomic]
Prognosis: [Expected response to treatment, timeline]
Contraindications: [Relative or absolute to treatment]
PLAN:
1. Chiropractic adjustments: [Techniques, frequency, regions]
2. Soft tissue therapy: [Massage, trigger point, instrument-assisted]
3. Therapeutic exercises: [Stretching, strengthening, stabilization]
4. Modalities: [Heat, ice, electrical stimulation, ultrasound]
5. Lifestyle modifications: [Ergonomics, posture, activity changes]
6. Patient education: [Condition explanation, self-care strategies]
7. Treatment frequency: [Schedule, duration of care plan]
8. Home care instructions: [Exercises, positioning, activity guidelines]
9. Re-evaluation: [Timeline for progress assessment]
10. Referrals: [Medical evaluation, imaging, specialists if needed]
Speech-Language Pathology

Speech-Language Pathology Assessment Template

Comprehensive template for SLP evaluations, treatment planning, and progress documentation

Speech-Language PathologyCommunication DisordersSwallowing
SOAP Note Template - Speech-Language Pathology
SUBJECTIVE:
Chief complaint: [Primary communication or swallowing concern]
History of present problem: [Onset, duration, progression, triggers]
Communication impact: [Social, academic, occupational effects]
Medical history: [Stroke, TBI, developmental delays, surgeries]
Swallowing concerns: [Difficulty, pain, choking, weight loss]
Voice changes: [Hoarseness, breathiness, pitch changes]
Previous therapy: [SLP services, response to treatment]
Educational history: [Academic performance, special services]
Family history: [Speech, language, hearing problems]
Social history: [Living situation, support systems, goals]
Hearing status: [Last audiogram, hearing aids, concerns]
OBJECTIVE:
Oral mechanism examination:
Structure: [Lips, tongue, palate, teeth, jaw symmetry]
Function: [Strength, coordination, range of motion]
Reflexes: [Gag, cough, swallow reflexes]
Speech assessment:
Articulation: [Sound production, error patterns]
Phonology: [Sound system, intelligibility]
Fluency: [Stuttering, rate, rhythm, prosody]
Voice: [Quality, pitch, loudness, resonance]
Language evaluation:
Receptive: [Comprehension, following directions]
Expressive: [Vocabulary, grammar, sentence structure]
Pragmatics: [Social use, conversation skills]
Swallowing assessment:
Oral phase: [Chewing, bolus formation, oral transit]
Pharyngeal phase: [Swallow initiation, clearance]
Signs of aspiration: [Coughing, throat clearing, wet voice]
Cognitive-communication: [Attention, memory, problem-solving]
Standardized test results: [Formal assessment scores]
ASSESSMENT:
Primary diagnosis: [ICD-10 code and SLP diagnosis]
Secondary diagnoses: [Additional communication disorders]
Severity level: [Mild, moderate, severe impairment]
Functional impact: [Communication effectiveness, safety]
Prognosis: [Expected outcomes, factors affecting progress]
Candidacy for treatment: [Motivation, cognitive status, support]
Recommendations: [Treatment approach, frequency, duration]
PLAN:
1. Treatment goals: [Short-term and long-term objectives]
2. Intervention approach: [Techniques, strategies, methods]
3. Treatment frequency: [Sessions per week, duration]
4. Therapy focus areas: [Speech, language, voice, swallowing]
5. Family/caregiver training: [Education, home practice]
6. Environmental modifications: [Communication strategies]
7. Augmentative communication: [AAC devices, strategies]
8. Swallowing strategies: [Safe swallowing techniques, diet]
9. Monitoring: [Progress measures, reassessment timeline]
10. Referrals: [Audiology, medical evaluation, other specialists]
11. Discharge planning: [Criteria, transition planning]

Ready to Automate Your SOAP Notes?

Stop filling out templates manually. Let AI generate personalized, compliant SOAP notes from your patient interactions in real-time.

Start Free Trial - 20 NotesSchedule Demo

Template Customization Tips

Make these templates work perfectly for your practice

Add Your Practice Information

  • • Include practice name and address
  • • Add your license numbers
  • • Insert contact information
  • • Include billing codes if needed

Customize Assessment Scales

  • • Add specialty-specific scales
  • • Include outcome measures
  • • Insert screening tools
  • • Modify rating systems

Adapt for Your Workflow

  • • Reorder sections as needed
  • • Add workflow checkboxes
  • • Include reminder prompts
  • • Insert common medications

Meet Legal Requirements

  • • Include state-specific requirements
  • • Add insurance requirements
  • • Insert facility protocols
  • • Include consent language

Add Smart Shortcuts

  • • Create dropdown menus
  • • Add checkbox options
  • • Insert common phrases
  • • Include auto-calculations

Quality Assurance

  • • Test with sample cases
  • • Review for completeness
  • • Check compliance standards
  • • Get colleague feedback

The Documentation Time Crisis

Healthcare professionals are drowning in paperwork. Here's how templates can help.

2.5
Hours Daily
Average time spent on documentation
73%
Report Burnout
Healthcare professionals citing documentation stress
30
Minutes Saved
Per note with standardized templates
95%
Compliance Rate
When using structured templates

"Templates gave me my evenings back"

"Before using structured templates, I was spending 3-4 hours every night on documentation. Now I finish my notes during the day and actually have time for my family."

- Sarah M., Nurse Practitioner

Frequently Asked Questions

Everything you need to know about using SOAP note templates

Are these templates legally compliant?

Yes, our templates include all standard SOAP note elements required for healthcare documentation. However, you should customize them to meet your specific state, insurance, and facility requirements.

Can I modify these templates?

Absolutely! These templates are designed to be customized. Add your practice information, modify sections, and adapt them to your specific workflow and requirements.

Will these work with my EMR system?

Most EMR systems allow you to create custom templates. You can copy our templates and paste them into your EMR's template builder or use them as a guide for structure.

How much time will templates save me?

Healthcare professionals typically save 20-30 minutes per note using structured templates, compared to writing from scratch. Over a typical day, this can save 2-3 hours.

Are there templates for my specialty?

We've included templates for the most common healthcare specialties. If you don't see your specialty, you can modify an existing template or contact us for a custom template.

What's better: templates or AI?

Templates are great for standardization, but AI takes it further by generating personalized content from your notes. Try our AI solution for the ultimate time-saving experience.

More SOAP Note Resources

Mental Health Examples

Depression, anxiety, PTSD templates

View Examples →

Nurse Practitioner

Primary care and specialty templates

View Guide →

Physical Therapy

Rehabilitation and assessment notes

View Guide →

All Specialties

15+ healthcare profession guides

View All →

Free Templates

Download and customize professional SOAP note templates

AI-Powered Notes

Let AI generate personalized SOAP notes automatically

24/7 Support

Get help with templates and documentation best practices