SOAP note examples

Subjective

58-year-old woman attending for annual diabetes review. Reports good adherence to metformin, no hypoglycaemic episodes. Occasional tingling in both feet in the evenings for about three months. No chest pain, breathlessness or visual change. Walks 20 minutes most days; non-smoker.

Objective

BP 138/84 mmHg (repeat 136/82). Weight 82.4 kg, BMI 29.6. HbA1c 58 mmol/mol (was 52). eGFR 84. Urine ACR 1.8 mg/mmol. Feet: pedal pulses present bilaterally, 10 g monofilament sensation reduced at both great toes, skin intact, no ulceration.

Assessment

Type 2 diabetes with suboptimal glycaemic control (HbA1c risen from 52 to 58 mmol/mol) and early sensory peripheral neuropathy. Hypertension adequately controlled on current therapy. Moderate cardiovascular risk; no evidence of nephropathy.

Plan

Increase metformin to 1 g twice daily with food; discuss GI side effects and safety in intercurrent illness. Repeat HbA1c in 3 months. Continue ramipril 5 mg daily; recheck BP in 3 months. Refer to podiatry for annual foot surveillance, moderate risk. Reinforce footwear and daily foot checks. Retinal screening invitation confirmed as sent. Review sooner if new numbness, foot wound or hypoglycaemia.

Subjective

41-year-old warehouse operative, four weeks of central lower back pain after lifting. Pain 6/10 on movement, 2/10 at rest, worse on prolonged sitting and forward bending, eased by walking. No leg pain, no numbness, no bladder or bowel change, no night pain, no weight loss.

Objective

Antalgic posture, reduced lumbar flexion (fingertips to mid-shin), extension full but uncomfortable. Tenderness over L4/L5 paraspinals. Straight leg raise 80 degrees bilaterally, negative. Power, reflexes and sensation intact in both legs. Sit-to-stand five times in 14 seconds.

Assessment

Non-specific mechanical low back pain, no red flags and no radicular features. Movement fear and deconditioning are the main barriers to recovery. Good prognosis for return to full duties.

Plan

Graded exposure programme: daily walking increasing by 5 minutes weekly, hip hinge retraining, sit-to-stand and dead-bug progressions twice daily. Advice on pacing and lifting technique at work; phased return to full lifting over three weeks. Reassurance and expected recovery timeline explained. Review in two weeks; escalate for medical review if new leg symptoms or any red-flag feature appears.

Subjective

33-year-old man, six weeks of low mood, poor sleep with early morning waking, loss of interest in cycling and reduced appetite. Started sertraline 50 mg two weeks ago; reports mild nausea only. Denies current thoughts of self-harm or suicide and has no plan; describes his partner and sister as supportive.

Objective

Well kempt, good eye contact, reactive affect but restricted range. Speech normal rate and volume. No psychotic features. PHQ-9 14 (was 18), GAD-7 9. Sleep diary shows five to six hours nightly. No evidence of alcohol or substance misuse.

Assessment

Moderate depressive episode, showing early response to sertraline at two weeks. Risk of self-harm assessed as low today, with protective social support and no history of attempt. Nausea consistent with expected early SSRI side effect.

Plan

Continue sertraline 50 mg daily for two further weeks, then review for increase to 100 mg if PHQ-9 remains above 10. Refer for guided CBT. Sleep hygiene plan and resumption of cycling twice weekly agreed. Safety plan documented with crisis line numbers; partner aware. Review in two weeks, or sooner if mood worsens or any thoughts of self-harm emerge.

SUBJECTIVE
Presenting complaint:
History (onset, duration, severity, course):
Relevant negatives:
Past medical history / medication / allergies:
Social and family context:

OBJECTIVE
Observations (BP, HR, temp, SpO2, weight/BMI):
Examination findings:
Investigations / results reviewed:

ASSESSMENT
Working diagnosis:
Differentials considered and why excluded:
Severity / risk:

PLAN
Treatment and prescriptions:
Investigations requested:
Referrals:
Safety-netting advice given:
Review interval:

SUBJECTIVE
Mechanism and duration of injury:
Pain (site, score at rest and on movement, aggravating/easing factors):
Red-flag screen (night pain, weight loss, bladder/bowel, saddle anaesthesia):
Function and occupational demands:
Patient goals:

OBJECTIVE
Posture and gait:
Range of movement:
Palpation findings:
Special tests:
Neurological screen (power, reflexes, sensation):
Outcome measures / baseline scores:

ASSESSMENT
Clinical impression:
Contributing factors and barriers to recovery:
Prognosis:

PLAN
Exercise prescription (sets, reps, frequency):
Manual therapy / adjuncts:
Education and self-management advice:
Work or activity modification:
Review date and escalation criteria:

SUBJECTIVE
Presenting concerns in the patient's words:
Symptom course since last review:
Sleep, appetite, energy, concentration:
Medication adherence and side effects:
Substance use:
Protective factors and support:

OBJECTIVE
Mental state examination (appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight):
Rating scales (PHQ-9, GAD-7, other):
Physical observations if relevant:

ASSESSMENT
Diagnosis / formulation:
Response to current treatment:
Risk assessment (self-harm, suicide, harm to others, safeguarding) and reasoning:

PLAN
Medication decision:
Psychological therapy / referral:
Safety plan and crisis contacts:
Who else is informed:
Review interval:

SUBJECTIVE
Change since last visit:
Adherence to agreed plan:
New symptoms or concerns:

OBJECTIVE
Repeat observations and measurements:
Focused examination:
New results since last visit:

ASSESSMENT
Progress against expected trajectory:
Revised diagnosis or staging, if any:

PLAN
Continue / change / stop:
Next investigations:
Review interval and safety-netting: