SOAP Note Example: Templates for Nursing, Rehab, and Counselling

Table of Contents

Objective, Assessment, and Plan. This guide gives three worked examples, a rule for sorting subjective from objective information, and the documentation standards Canadian students are marked against. Checked against Canadian college standards and StatPearls in September 2026.

Quick Answers

Question	Answer
What does SOAP stand for?	Subjective, Objective, Assessment, Plan
Who uses it?	Nursing, medicine, physiotherapy, occupational therapy, counselling
How long is a SOAP note?	A short paragraph per section, often half a page
Where does a patient-reported number go?	Subjective, even when it is a measurement
What belongs in Assessment?	Your interpretation of the data, not the data again
Can a student write a diagnosis?	No. Report findings, progress, and clinical concern

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What Is a SOAP Note?

A SOAP note is a progress note written after a patient or client encounter, structured in four fixed sections.

Lawrence Weed developed the format in the 1960s as part of the problem-oriented medical record. The StatPearls entry on SOAP notes describes it as both a documentation method and a framework for clinical reasoning.

The order carries the logic. The patient’s report and your observations support your interpretation. Your interpretation supports your plan. An Assessment that introduces something absent from the first two sections breaks its own argument.

What Goes in Each Section?

Section	What belongs	Common error
Subjective	The patient’s report: symptoms, history, concerns, quotations, family input	Adding your own observations
Objective	What you measured or observed: vitals, exam findings, test results, behaviour	Slipping in interpretation
Assessment	Your interpretation: what the data indicates, progress toward goals, concern	Restating the data
Plan	Interventions, education, referrals, follow-up, next visit	Writing something nobody can act on

Subjective or Objective: How Do You Decide?

Sort by the source of the information, not by how factual it sounds. Information from the patient or their family is subjective, even when it arrives as a number.

Item	Section	Why
“I’ve had a headache for three days”	Subjective	The patient’s report
Temperature of 38.2 that you took	Objective	You measured it
“I checked my blood pressure at home, it was 160 over 95”	Subjective	A patient-supplied number is still a report
The daughter says he has been confused since Tuesday	Subjective	Information from a family member
“The client reports feeling on edge all week”	Subjective	The client’s words
The client fidgets and makes little eye contact	Objective	Your observation

Pain scores sit on the line. A rating of 7 out of 10 is patient-reported, so it belongs in Subjective. Some programs record it under Objective with the vital signs. Check your template.

Nursing SOAP Note Example

A 68-year-old patient, post-op day two from abdominal surgery, reports incisional pain at 6 out of 10, worse on movement. States the medication “helps for a couple of hours, then wears off.” Reports no nausea and poor sleep.
Temperature 37.1, heart rate 92, blood pressure 118 over 74, respiratory rate 18, oxygen saturation 97 percent on room air. Incision clean and dry, edges approximated, no redness or drainage. Bowel sounds present in all quadrants. Mobilized to the chair with one assist, guarding on transfer.
Pain is controlled for part of the dosing interval, with breakthrough before the next dose. No signs of wound infection or respiratory complication. Mobility is limited by pain rather than strength.
Administer analgesia as ordered and reassess 30 minutes after. Discuss the dosing interval with the prescriber. Encourage mobilization after analgesia. Continue incision assessment each shift and hourly deep breathing while awake.

Physiotherapy SOAP Note Example

Rehabilitation notes carry measurements in Objective and progression in Plan.

Client reports the knee feels “more stable on stairs” this week. Denies swelling after the last session. Completed the home program five of seven days.
Knee flexion 118 degrees, up from 105 last session. Extension to neutral. Quadriceps strength 4 out of 5. Single-leg stance held 22 seconds. No effusion on palpation. Step-down at 15 cm with good control.
Range of motion and single-leg stability continue to improve, consistent with the expected trajectory at this stage. Quadriceps strength remains the limiting factor for stair descent.
Progress step-down to 20 cm next session. Add closed-chain strengthening twice weekly. Update the home program and reassess flexion in two weeks.

Counselling SOAP Note Example

In mental health notes, Objective means observed behaviour and mental status rather than vital signs.

Client reports increased worry about a work deadline and sleep onset difficulty most nights this week. Used the breathing exercise twice and found it “a bit helpful.”
Attended on time. Speech normal in rate and volume. Affect anxious, congruent with content. Oriented and engaged throughout. No expressed thoughts of harm to self or others.
Anxiety symptoms remain present and are situational around work demands. Partial use of the between-session strategy suggests the technique is acceptable but not yet habitual.
Continue weekly sessions. Review the breathing exercise and set a daily cue. Introduce cognitive restructuring for deadline-related thoughts next session.

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How Do You Write the Assessment Without Diagnosing?

A student’s Assessment interprets the data. It does not assign a medical diagnosis. Say what the findings indicate, how the patient is progressing against goals, and what concerns you.

Many online examples come from practising clinicians in other jurisdictions. A line like “assessment: major depressive disorder” reads differently in a Canadian student submission. Scope is set provincially, so check your college’s standards, such as the College of Nurses of Ontario or the College of Physiotherapists of Ontario.

Weak: “Patient has pain 6 out of 10 and stable vitals.”

Strong: “Pain is controlled for part of the dosing interval, with breakthrough before the next dose, and mobility is limited by pain rather than strength.”

The weak version repeats the data. The strong version says what the data means.

How Do You Write a Plan Someone Else Can Follow?

Name the intervention, the frequency, the education you gave, any referral, and what happens next visit.

Weak: “Continue current treatment and monitor.”

Strong: “Administer analgesia as ordered and reassess 30 minutes after. Discuss the dosing interval with the prescriber. Encourage mobilization after analgesia.”

Vague plans lose marks because they are unusable, not because they are short.

What Changes When a SOAP Note Is an Assignment?

Five things separate a submitted note from a chart entry.

Remove every identifier. No names, room numbers, dates of birth, or facility. Write “a 68-year-old patient” or use initials if your program allows.
Write full sentences where the template allows. Chart shorthand reads as unfinished work.
Hold your tense. Past tense for the encounter, present tense for the current picture.
Follow the program template, which may split sections or add goal tracking.
Cite where required. Our APA guide covers the format, and longer write-ups often follow case study structure.

What Do Canadian Documentation Rules Require?

Provincial legislation and your regulatory college govern health records. Ontario’s Information and Privacy Commissioner oversees personal health information, and every college publishes documentation expectations.

Three conventions students meet late:

Never erase an entry. A record with removed content raises questions a correction never would.
Label late entries. Give the time you wrote it alongside the time of the care.
Add corrections as dated addenda rather than editing the original.

SOAP vs DAP vs PIE vs SBAR

Format	Sections	Used for
SOAP	Subjective, Objective, Assessment, Plan	General progress notes across disciplines
DAP	Data, Assessment, Plan	Counselling, merging subjective and objective
PIE	Problem, Intervention, Evaluation	Nursing notes tied to a care plan
SBAR	Situation, Background, Assessment, Recommendation	Spoken escalation and handover

SOAP documents an encounter after the fact. SBAR moves information between people in the moment, covered in our SBAR guide.

Five Mistakes That Cost Marks

Your own observations filed under Subjective.
Interpretation slipped into Objective.
An Assessment that repeats the data.
A Plan nobody can act on.
Identifying details left in a submitted note.

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Frequently Asked Questions

What does SOAP stand for in a SOAP note?

SOAP stands for Subjective, Objective, Assessment, Plan. Lawrence Weed developed the format in the 1960s as part of the problem-oriented medical record. It is now used across nursing, medicine, physiotherapy, occupational therapy, and counselling to document patient encounters.

What is an example of a SOAP note?

A SOAP note example records one encounter in four sections: what the patient reported, what you measured or observed, your interpretation, and the plan. This article includes three worked notes for nursing, rehabilitation, and counselling, since the Objective section differs by discipline.

What is the difference between subjective and objective in a SOAP note?

Subjective covers information from the patient or family, including symptoms, history, and quotations. Objective covers what you measured or observed, such as vital signs, exam findings, and behaviour. Sort by source rather than by how factual the information sounds. A blood pressure reading the patient took at home is subjective.

What goes in the assessment section of a SOAP note?

Your interpretation of the subjective and objective data: what the findings indicate, progress toward goals, and any clinical concern. It should not repeat the data or introduce new information. Students report findings and concerns rather than assigning a medical diagnosis, since scope of practice is set by the provincial college.

How long should a SOAP note be?

A routine progress note runs a short paragraph per section, often half a page. Complex encounters run longer, and initial assessments longer again. Academic submissions follow the program template and word count, and expect full sentences instead of chart shorthand.

Can someone help me with my nursing or allied health assignments?

Yes. Homework Help Global works with Canadian nursing, rehabilitation, and counselling students on SOAP notes, care plans, case studies, and reflective assignments. We check structure against the rubric, strengthen clinical reasoning, and confirm de-identification. Send your draft through the free quote form for a price before any work starts.