Brief SOAP Note

Uses concise S, O, A, and P sections to capture the visit reason and relevant history, objective findings or completed investigations, active issues with reasoning, and management steps. It prompts for brevity while retaining follow-up and return precautions.

Use for a routine visit when a concise, structured note is sufficient to document the history, findings, assessment, and plan.

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Completed note example

See how this format reads in practice. The reusable template and supporting clinical facts are below.

Completed note

S:
- Two days of intermittent nasal congestion and sneezing, worse in the morning.
- Denies fever, facial pain, or shortness of breath. No daily medications.

O:
- HR: 76 bpm, BP: 116/70 mmHg, T: 36.8 °C, RR: 14/min, O2 sats: 99% on room air
- General: Well appearing
- Nose: Mild clear rhinorrhea; no focal sinus tenderness
- Lungs: Clear to auscultation

A:
- Acute rhinitis, likely allergic based on sneezing and clear rhinorrhea; viral illness remains a differential.

P:
- Trial saline nasal irrigation and reduce exposure to suspected triggers.
- Discussed an over-the-counter non-sedating antihistamine according to package directions if symptoms persist.
- Follow up if symptoms worsen or fail to improve; seek urgent care for breathing difficulty or high fever.

Illustrative case with invented patient details. This is not a real patient record or clinical guidance. Review each note against your own consultation.

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Clinical facts behind the note

chief complaint

Nasal congestion and sneezing for two days

symptoms

Symptoms worse in the morning

denials of symptoms

No fever

No shortness of breath

vital signs

Temperature 36.8 °C and oxygen saturation 99%

physical exam

Clear rhinorrhea without focal sinus tenderness

assessment

Rhinitis likely allergic; viral illness remains a differential

plan

Saline irrigation, trigger reduction, and follow-up guidance

Reusable template structure

<b>S:</b>
(hyphenated list)
- [Brief statement of chief complaint or reason for visit]
- [Relevant associated history in chronological order]
- [Past medical history if relevant]
- [Medications if relevant]

<b>O:</b>
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings directly examined] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>A:</b>
(hyphenated list)
- [Diagnosis and reasoning] (Use medical terminology if appropriate.  Only include active issues being managed during the visit, do not list stable chronic conditions, resolved issues, or past medical history)
- [Differential diagnosis if mentioned]

<b>P:</b>
(hyphenated list)
- [Investigations planned or ordered]
- [Treatment plan]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]


(ensure note is as concise as possible)

Your consultation. This note format.

Save your own copy of this template, adjust the structure, and record your consultation. Notat extracts the clinical facts first. The FactsContext™ engine then writes the note from those facts, so you can check what supports it before editing and signing.

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Use this format for your next consultation

Keep the structure. Let Notat write the note from your consultation, then review and edit it.

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