SOAP notes are a little like Facebook. Everyone uses SOAP notes because everyone they know uses SOAP notes.
Developed by Dr. Lawrence Weed in the 1960s, healthcare professionals enter SOAP notes into their patient’s medical record to communicate vital information to other providers of care, to provide evidence of patient contact, and to inform the Clinical Reasoning process.
If you’re one of the zillions of healthcare professionals who uses SOAP notes, you may be looking for some good, free SOAP notes templates, along with Electronic Health Records software (EHRs) that include templates and/or templating functionality.
Don’t worry, I got your back.
What are SOAP notes?
SOAP notes have four parts:
Subjective is about how the patient and you perceive the patient to be doing.
This includes how the patient looks and feels and their recent activity. This section is where you’ll record things like the etiology or mechanism of injury, chief complaint, symptoms, and description of pain. It also includes the medical history, which should take up the majority of the note.
Objective is how the patient is actually doing based on objective measures including a physical exam, vital signs, ins and outs, and recent results from labs, cultures, and other tests.
For a physical therapist, this portion might include vision, palpation—soft and bony, girth, ROM (Range of Motion)—AROM, PROM and RROM which stands for Active, Passive and Resistive Range of Motion, manual muscle tests, neurological assessment, circulation, and special tests.
The assessment includes a list and brief summary of the patient’s active issues along with a description of any significant changes since the last time you took notes.
The plan is the treatment you intend to implement, including long-term treatment plans and lifestyle recommendations. It contains all the required steps, and details every proposed treatment, including medication, therapies, and surgeries.
In the medication section, include all antibiotics and the number of days they’ve been on them. For example, Gentamicin day 7/14. Some medical professionals record medications in the upper right hand corner of the page.
For surgical patients, begin the plan portion with “POD # (post-op day number, with the day after surgery being post-op day 1) s/p (status post) procedure.”
It should also include your short- and long-term goals for the patient.
Sample SOAP note (Source)
Totally free SOAP notes templates
Teachers Pay Teachers and FreePrintableMedicalForms have blank SOAP notes templates available for download for free, but if you’re willing to pay a few dollars, they’ve also got forms available in DOCX and PDF which you can fill out electronically instead of having to print out, fill out, and then transcribe. Most of the templates on Teachers Pay Teachers are for speech therapy, but nursing is also included.
SampleTemplates.com has SOAP note templates in DOCX format for nursing, physical therapy, and other specialties. They’re not filled out with sample text but they do contain descriptions of each part of the SOAP note, which you may or may not find helpful.
For massage therapists, My Massage World has great, free downloadable PDFs.
EHRs with built-in SOAP notes templates
Some EHRs offer built-in SOAP notes templates.
You can also create your own templates with Kareo. Another reviewer writes, “I was able to create custom templates that fit my practice, which makes visit documentation a breeze.”
Some EHRs such as Radekal App by Pertexa Healthcare Technologies and NueMD allow you to set up your common general exam findings as templates and create canned responses that you can use to pre-fill 90% of your predefined normals in one click, then quickly and easily add any abnormal findings.
Some EHRs such as Praxis EMR, don’t use templates at all on the theory that templates are rigid, cumbersome, frustrating to use, and limit your freedom.
SOAP notes are also like Facebook in that many people use them, but everyone uses them a little differently.
If you find an EHR with built-in templates that will work for your practice and that allows you to create automated responses, this is your best bet. It will save you a lot of time in your charting. Otherwise, find a good template that you can edit online and save to your EHR, and customize it for your needs.
To compare EHR systems, check out our EHR directory. And if you have any other good sources for free SOAP notes templates, let me know in the comments!
Looking for Medical Practice Management software? Check out Capterra's list of the best Medical Practice Management software solutions.