S
Subjective
Sharp pain under the left heel, worst on the first few steps in the morning and after rest. Three weeks, gradual onset. No trauma. New to running.
The clinical documentation standard
Write the note
Write the note
the way you were
taught to think.
SOAP is the shared language of clinical reasoning — four parts that turn an encounter into a record any clinician can read, defend, and continue.
A real note, structured in seconds — read on to see how each part works.
Left heel pain · initial assessment
•PODIATRY
•07 Jul 2026
O
Objective
Tender at the medial calcaneal tubercle. Windlass test positive. Ankle dorsiflexion 5° (tight gastrocnemius). No swelling, pulses intact.A
Assessment
Plantar fasciitis, left, mechanically driven by reduced ankle dorsiflexion and a rapid load increase.P
Plan
Calf-stretch program, gel heel cup, load management advice. Review in 3 weeks; consider night splint if morning pain persists.
The framework
What is a SOAP note?
A SOAP note is a structured method of clinical documentation that records a patient encounter in four sections — Subjective, Objective, Assessment and Plan. It moves in the same order a clinician actually reasons: from what the patient tells you, to what you measure, to what you conclude, to what you do next.
The format grew out of the problem-oriented medical record introduced by Dr Lawrence Weed in the 1960s, and it has since become the default across physiotherapy, podiatry, nursing, mental health, veterinary practice and beyond. Its staying power is simple: it makes clinical thinking legible. A colleague picking up the chart, an auditor reviewing it, or you yourself six months later can all follow exactly what happened and why.
A good SOAP note isn't a transcript of the visit — it's the reasoning behind it, written down.
Anatomy
The four parts, one at a time
Each section answers a different question. Keep them separate and the note stays honest — findings don't leak into opinions, and the plan always traces back to the evidence.
S
Subjective
What the patient tells you
The story in the patient's own words — the presenting complaint, its history, symptoms, and how it affects their life. Reported, not measured.
e.g. "Sharp heel pain, worst on the first steps each morning, three weeks."
O
Objective
What you observe and measure
The findings anyone could verify — examination results, range of motion, test outcomes, vitals, imaging. Facts, free of interpretation.
e.g. "Tender at medial calcaneal tubercle. Windlass test positive. DF 5°."
A
Assessment
What you conclude
Your clinical judgement — the diagnosis or working impression that ties the subjective story to the objective findings. Where reasoning lives.
e.g. "Plantar fasciitis, left, driven by limited dorsiflexion and load spike."
P
Plan
What happens next
The action — treatment, advice, referrals, prescriptions, and the review interval. Specific enough that the next clinician knows exactly what to do.
e.g. "Calf-stretch program, heel cup, review in 3 weeks."
In practice
How to write a good SOAP note
The structure is easy; the discipline is keeping each part to its job. A few habits separate a note that stands alone from one that raises questions.
Keep opinion out of Objective
"Antalgic gait" is an interpretation; "reduced weight-bearing on the left, shortened stance phase" is what you saw. Save the conclusion for Assessment.
Make the Assessment earn its place
Every impression should be traceable to something in S and O. If it isn't supported above, either the finding is missing or the conclusion is a leap.
Write a Plan the next clinician can act on
Name the intervention, the dose, the advice, and the review point. "Continue as before" tells a covering colleague nothing.
Write it to stand alone
Assume the reader wasn't in the room. Date it, attribute it, and include enough that care could continue from the note without you.
Why it endures
Structure that protects the patient — and you
Continuity of care
Any clinician can pick up the record and continue treatment without losing the thread. The plan always points forward.
Medico-legal defensibility
A clear, dated, reasoned note is your best record if a decision is ever questioned. Separating fact from opinion is what makes it hold up.
Sharper clinical reasoning
Forcing the assessment to follow the evidence exposes gaps — the note that's hard to write is usually the case worth rethinking.
Faster handover
The four-part shape is scannable. A colleague finds the finding, the impression, and the next step in seconds, not paragraphs.
Beyond the four parts
SOAP, extended: SOAPE, SOAPIE and more
Some disciplines add sections to close the loop on treatment — an evaluation, an intervention, a revision. Same trusted core, extra fields for how you follow patients up.
For clinicians
One framework, every discipline
SOAP travels well because clinical reasoning is universal. The vocabulary shifts, the structure doesn't — which is why it's taught across the professions.
Physiotherapy
Podiatry & foot health
Chiropractic
Massage & sports therapy
Nursing
Mental health & counselling
Occupational therapy
Veterinary practice
Osteopathy
From spoken to structured
Say the visit. Keep the note.
SOAP Notes listens to how you already talk through a case and lays it out in the four parts — so the framework does the filing, and you keep your attention on the patient.
01Speak or typeDictate the encounter in your own words, hands-free.
02Structured into S·O·A·PEach part sorted into place — or an extended format if you prefer.
03Yours, on your deviceEncrypted locally. The plaintext never leaves your phone.
Your record, your rules•PRIVATE BY DESIGN
∎
Zero-knowledge
Notes are encrypted on-device. Cloud backup, when you choose it, is sealed before it leaves — we can't read it.∎
Works anywhere
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Common questions
SOAP notes, answered
What does SOAP stand for?
Subjective, Objective, Assessment, Plan — the four sections of the note, in the order a clinician reasons through an encounter.
What's the difference between a SOAP note and a DAP note?
DAP (Data, Assessment, Plan) merges the subjective and objective into a single "Data" section. SOAP keeps them apart, which is why it's preferred where separating what the patient reported from what you measured matters — most physical and medical disciplines. DAP is common in mental health, where the distinction is softer.
How long should a SOAP note be?
As short as it can be while still standing alone. A focused follow-up might be a few lines per section; a complex initial assessment more. Length isn't the measure — a good note is complete enough that another clinician could continue care from it.
What's the most common mistake in a SOAP note?
Letting interpretation leak into the Objective section, or writing an Assessment the findings don't support. Keeping each part to its own job — reported, measured, concluded, planned — is what keeps the note defensible.
Are SOAP notes a legal record?
Yes. Clinical notes form part of the patient's medical record and can be called on in audits, complaints or legal proceedings. A dated, structured, reasoned SOAP note is far easier to stand behind than a loose narrative.
Can I dictate a SOAP note instead of typing it?
That's exactly what the SOAP Notes app is for — you talk through the case and it structures your words into the four parts, so you're reviewing a draft instead of writing from a blank page.
Better notes start with better structure.
Learn the framework, then let the app keep it for you — free to start, on your device from the first note.
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