How to Write Objective in SOAP Notes (with Examples)

The Objective section in a SOAP note is one of the most important parts of clinical documentation. It contains the facts you can see, hear, measure, or test, and it helps show the true condition of the patient. When this section is written clearly, it supports better decisions, improves communication between providers, and makes the whole note easier to understand. Many clinicians, especially new ones, are unsure about what belongs in the Objective section and how much detail they should include. Some write too little, while others write too much. This guide explains the Objective section in simple words so you can write it with confidence. You will learn what to include, how to organize your findings, and how to avoid common mistakes. We also share examples and tips that make the writing process easier, faster, and more accurate for every type of clinician.

What Is the Objective in SOAP Notes?

The Objective section contains information you can see, hear, measure, test, or record. It does not include feelings, guesses, or assumptions. Instead, it focuses on facts.

You collect this information through physical exams, vital signs, lab tests, imaging reports, and direct observations. Because it relies on measurable data, the Objective section makes your SOAP note trustworthy and useful for other providers. Sometimes clinicians mix subjective and objective information. But this confuses the reader. Remember: Objective = facts only.

Why the Objective Section Matters

The Objective section helps clinicians track a patient’s health over time. It also supports your Assessment and Plan. If your objective data is weak, the entire note becomes weak. Insurance companies, supervisors, and other providers often look at this section first to understand the clinical picture.

When objective data is clear, it reduces medical errors. It also protects you legally because you show proof of what you observed and measured. This can be very important during audits or patient complaints.

Strong objective documentation also improves communication. It helps nurses, therapists, physicians, and specialists work together more easily. Everyone sees the same measurable results.

What to Include in the Objective Section

Below is a list of what commonly goes into the Objective section. You can use this as a basic checklist.

Vital Signs

• Blood pressure
• Heart rate
• Respiratory rate
• Temperature
• Oxygen saturation
• Pain score (if recorded)

Physical Examination Findings

• General appearance
• Skin
• Cardiovascular
• Respiratory
• Abdomen
• Musculoskeletal
• Neurological
• Mental status
• HEENT (Head, Eyes, Ears, Nose, Throat)

Measurements

• Weight
• Height
• BMI
• Blood sugar reading
• Peak flow
• Gait distance
• Range of motion

Diagnostic Results

• Lab reports
• X-rays
• MRI
• Ultrasound
• ECG findings

Clinical Observations

These are things YOU observe:

• Patient limping
• Slurred speech
• Swelling or redness
• Difficulty breathing
• Mood or behavior changes
• Wounds or lesions

Treatment Response

Only if it is measurable, such as:

• Pain reduced from 8/10 to 4/10
• BP improved after medication
• Wound size decreased from 5 cm to 3 cm

How to Write the Objective Section Step-by-Step

Below is a reliable system you can follow when documenting the Objective section. Many clinicians find this structure very helpful because it reduces confusion, saves time, and keeps the note focused. By following these steps, you create a clear and organized flow that makes your SOAP notes easier to read and more clinically accurate.

Start With Vital Signs

Begin the Objective section by recording the most important vital signs. These numbers give an immediate snapshot of the patient’s current clinical status and help determine how urgent the situation is.

Vital signs include blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and sometimes the pain score if it was measured. Listing these first helps set the foundation for the rest of the Objective section and allows other providers to quickly interpret the patient’s stability.

Add General Appearance

After vital signs, document the patient’s overall appearance. This should include observations made the moment the patient enters the room or when you first interact with them. Write what you see, not what you assume. Focus on hygiene, posture, alertness, mobility, eye contact, and visible distress or discomfort. General appearance provides context for the rest of the physical exam, especially if the patient looks ill, tired, anxious, or in pain.

Document Physical Exam Results

Record physical exam findings in a clear, system-by-system format. This keeps your documentation organized and ensures you don’t overlook important details. You may examine systems such as HEENT, cardiovascular, respiratory, abdomen, musculoskeletal, neurological, or skin—depending on the visit.

Use short sentences to describe what you observed. Stick to measurable or visible findings and avoid long explanations or interpretations. Remember, this part should remain fully objective; your reasoning and diagnosis belong in the Assessment section.

Add Measurements and Quantitative Data

Include all measurable data you collected during the encounter. This can be numbers such as weight, height, BMI, blood sugar readings, peak flow, range of motion values, grip strength scores, or wound measurements.

Quantitative data strengthens your note because numbers provide clear evidence of the patient’s condition. Avoid guessing or estimating any values. If something could not be measured, state that it was “not assessed” rather than adding vague descriptions.

Include Diagnostic Results

If the patient received diagnostic tests during the visit, add the results here. This may include lab reports, X-rays, MRIs, ECG interpretations, or point-of-care test results. Diagnostic findings give objective support for your Assessment and help refine clinical decisions. If results are not yet available, it is completely acceptable to write “results pending.” This is helpful because it alerts other providers to follow up later and prevents confusion about missing data.

Finalize With Clinical Observations

End the Objective section with any other observable or measurable findings that did not fit into the earlier categories. These can include gait changes, speech patterns, visible swelling, abnormal movements, breathing difficulty, wound appearance, or behavioral signs you directly witnessed.

This final step allows you to include important details that support the patient’s condition without drifting into subjective impressions. Observations should remain factual and descriptive, helping paint a complete picture of the patient’s health during the visit.

Examples of Objective in SOAP Notes

Here are some objective SOAP note examples you can use for your own notes.

Example 1: Primary Care

O:

BP 132/84, HR 88, RR 16, Temp 98.4°F.

Patient alert and oriented ×3. Lungs clear bilaterally. No wheezing.

Abdomen soft, no tenderness.

Weight 78 kg, BMI 28.1.

Fasting sugar measured at clinic: 148 mg/dL.

Example 2: Mental Health (Medical Side Only)

O:

Affect flat. Eye contact limited.

Speech slow but coherent.

No tremors. Gait steady.

BP 118/68.

Lab results: TSH 1.9 (normal).

Example 3: Physical Therapy

O:

Gait assisted with cane. Stride length reduced.

ROM left knee: 80° flexion, 10° extension.

Strength 4/5 on left leg, 5/5 on right.

Pain score: 6/10 before session, 4/10 after.

Example 4: Pediatrics

O:

Temp 100.2°F. HR 104.

Child appears tired. Mild nasal discharge.

Lungs: scattered rhonchi.

Weight: 18 kg.

Rapid flu test: negative.

Example 5: Wound Care

The wound is located on the right lower leg. Size: 4 cm × 3 cm. Depth 0.5 cm. Moderate serous drainage noted.

Edges clean. Surrounding skin slightly red but not warm.

Pain score 3/10 during dressing change.

No foul smell. No signs of infection observed at this time.

Best Practices for Writing Strong Objective

The tips below will help you write a clean and well-structured objective. They are designed to make your Objective section complete, accurate, and easy to review, and they work well for physicians, nurses, therapists, and all healthcare professionals who use SOAP notes.

Be Clear and Measurable

Use numbers whenever possible. Measurable data removes confusion and strengthens your clinical reasoning. Instead of saying something general like “improved” or “looks better,” include exact values such as temperature, wound size, pain score, or range of motion.

Avoid words like “better” or “worse” without data, because they do not show what actually changed. Numbers make your findings objective and defensible.

Write What You See, Not What You Think

Objective = facts.

Assessment = thoughts.

These two sections must always be separate. Your job in the Objective section is to show the measurable or observable information you collected—not what you believe the cause might be. By keeping facts in the Objective section and analysis in the Assessment, your notes stay clear and professional.

Never mix them, because doing so weakens your documentation and makes your clinical reasoning harder to follow.

Avoid Subjective Words

Certain words automatically introduce opinion, and they do not belong in the Objective section. Words to avoid:

• “Seems”
• “Maybe”
• “Appears anxious”

These phrases sound uncertain and subjective. Instead, replace them with specific, observable facts such as changes in behavior, posture, or speech.

Better version: “Patient pacing and fidgeting.”
This describes what you saw without guessing or interpreting emotion.

Use Short, Simple Sentences

Using short, simple sentences keeps your writing clean and fast to read. This is especially important in fast-paced clinical environments where multiple providers rely on your documentation.

Simple sentences also make it easier for you to write quickly without sacrificing accuracy. Long, complicated sentences tend to mix subjective opinions with objective facts, so keeping things brief helps your notes stay sharper and more objective.

Follow the Same Structure Each Time

Using a consistent pattern reduces mistakes and saves time. Whether you prefer starting with vitals, then appearance, then physical exam, or another structure, keeping the same order helps your brain work faster and prevents missed details. A predictable structure also helps other clinicians quickly interpret your notes. When everyone uses the same flow, teamwork becomes smoother, and patient care becomes safer.

Include Only Relevant Details

Avoid documenting normal findings in long sentences. Be brief and focused on what matters for the patient’s visit. For example, if the system is normal, you can simply write “Lungs clear bilaterally” instead of adding unnecessary sentences. Adding too much detail can hide the important findings and slow down the reader. Good Objective notes highlight what is clinically useful, not everything you could possibly mention.

Use Templates for Speed

Having a structure ready helps you write faster and more accurately. Templates reduce mental load and ensure you never forget key information like vitals, exam findings, or measurements.

Many clinicians use pre-made templates inside their EHR or AI tools like Skriber because they keep the Objective section clean and consistent. Templates also improve documentation quality, especially during busy clinic days when notes must be completed quickly without losing accuracy.

Common Mistakes in the Objective Section

These are mistakes clinicians often make, and here’s how to fix them.

Mistake 1: Mixing Subjective and Objective ->

Bad: “Patient looks sad and says pain is unbearable.”
Good:

• Objective → “Tearful, slow movement.”
• Subjective → goes in the S section.

Mistake 2: Missing Important Measurements -> Always check vitals, weight, and physical exam basics.

Mistake 3: Using Jargon– > Avoid complex medical words if simple words can explain the same thing.

Mistake 4: Guessing -> If you are not sure, leave it out or say “unable to assess.”

Mistake 5: Writing Too Much -> Stick to measurable findings. Long descriptions without data reduce clarity.

Examples of Objective vs. Subjective Data

Subjective (Patient Reports)	Objective (Clinician Observes/Measures)
“My chest hurts”	BP 150/90, HR 110, abnormal ECG
“I feel dizzy”	Unsteady gait, pale appearance
“My knee is swollen”	Visible swelling, ROM 60°, warmth noted
“I think I have a fever”	Temp 101.2°F
“I feel weak”	Strength 3/5 left arm

How Objective Data Supports the Assessment and Plan

Objective data helps you create an accurate Assessment. Without objective findings, your diagnosis becomes weak. For example, if a patient complains of severe chest pain, but you documented no BP, ECG, or lung exam, your assessment loses credibility.

Accurate objective information also helps build the treatment Plan. For example:

• ROM measurements guide physical therapy goals
• Blood sugar levels guide diabetes medication
• Temperature changes guide infection treatment

When objective data is strong, the Assessment and Plan become strong too.

Objective Section for Different Healthcare Settings

The Objective section changes based on your specialty. Here is how it looks in different fields.

Primary Care

Primary care clinicians include:

• Vital signs
• Physical exam
• Screening results

They usually cover many body systems in one visit.

Mental Health

Mental health clinicians focus on:

• Appearance
• Behavior
• Speech
• Orientation
• Psychomotor activity

(They do not diagnose medical conditions unless trained.)

Physical Therapy

PTs use:

• Mobility tests
• ROM
• Strength grading
• Gait observation
• Special tests

Everything must be measurable.

Occupational Therapy

OTs document:

• Functional tasks
• Grip strength
• Coordination
• ADL performance

These are also objective and observable.

Nursing

Nurses focus on:

• Vitals
• Pain
• Skin
• Wounds
• IV lines
• Medication response

They keep the Objective section very detailed.

Objective Writing Template

Below is a simple template you can use in any SOAP note.

SOAP Note Objective Template

O:

Vitals: BP __ / __, HR __, RR __, Temp __, O2 Sat __%, Pain __/10

General Appearance:
__

Physical Exam:

• HEENT: __
• Cardiovascular: __
• Respiratory: __
• Abdomen: __
• Musculoskeletal: __
• Neurological: __
• Skin: __

Measurements:

Weight __, Height __, BMI __, Blood sugar __, Other readings __

Diagnostics:

Lab results: __

Imaging: __

Other tests: __

Clinical Observations:
__

Advanced Tips for Better Objective Documentation

Here are some advanced techniques from my experience that clinicians can use to write faster, clearer, and more consistent Objective sections. 

Start With Abnormal Findings

Put abnormal findings first, especially when they are clinically important. This immediately draws attention to the areas that need the most urgent follow-up and prevents the reader from having to search through the note to find key details. Placing unusual results at the top also creates a logical flow for the Assessment because it directly highlights what needs to be addressed. This simple habit can significantly improve the clarity of your documentation.

Use Numbers More Often

Numbers make your documentation stronger and more defensible. Quantitative data gives a clear picture of the patient’s condition and removes guesswork from your note.

Examples:

• “Walked 30 meters without support.”
• “Wound reduced by 20%.”
• “Pain decreased from 7 to 3 after treatment.”

Using numbers wherever possible allows other clinicians to track changes over time and see whether treatment is working.

Use Standardized Tools

Standardized tools create reliable, consistent documentation. They help measure symptoms and functions in a way that other clinicians can easily understand and compare across visits.

Examples include:

• GCS (Glasgow Coma Scale)
• MMSE
• PHQ-9 (scores only)
• Pain numeric scale
• Strength grading 0–5

These scales provide structured, objective data and support better clinical judgments.

Keep a Short List of Common Phrases

Having a small set of common, prewritten phrases saves a lot of time. These phrases help you document normal exam findings quickly without having to rewrite them in every note.

For example:

• “Lungs clear bilaterally.”
• “No edema in lower limbs.”
• “Pupils equal and reactive.”

Keeping these phrases ready also helps maintain consistency and reduces errors during busy shifts.

Do Not Rely on Memory

Always document during or right after the visit. Memory fades quickly during a busy clinical day, and even small details can be forgotten. Writing notes immediately ensures your Objective findings are complete, accurate, and fresh.

Documenting early also prevents confusion later on and reduces the risk of mistakes that could impact patient care.

Frequently Asked Questions

Should I include patient quotes in the Objective section?

No. Quotes belong in the Subjective section because they reflect what the patient reports, not what you observe. The Objective section should always contain measurable or observable findings only.

Should I include social or emotional behavior?

Only if you observe it directly. If you see a patient crying, pacing, or avoiding eye contact, you may document it as an observable fact.

Example: “Patient crying during interview.”
This is objective because you witnessed it yourself, not because the patient said it.

Should normal findings be included?

Yes, but keep them short. Normal findings give useful context, but they do not need long explanations. A simple phrase like “Lungs clear bilaterally” or “Normal gait” is usually enough.

Can I write “WNL”?

Avoid it. Some auditors dislike “WNL” because it can be vague and inconsistent. Writing out the actual normal finding is clearer and more professional.

Should I include pending labs?

Yes. If lab results are not yet available, document them as pending.

Write: “CBC pending.”
This helps other clinicians know that results are expected and should be reviewed later.

How long should the Objective section be?

As long as needed, but always concise. The goal is to include all relevant measurable data without adding unnecessary detail. A well-written Objective section is clear, focused, and easy for others to scan quickly.

Conclusion

The Objective section plays a key role in making SOAP notes accurate, clear, and useful for patient care. When you focus on measurable facts, organize your findings properly, and avoid mixing opinions with observations, your documentation becomes stronger and easier for other clinicians to follow. Using consistent steps, simple language, and helpful tools like templates or standardized measures can save time and improve the quality of your notes. With the above tips, examples, and guidance, you can confidently write Objective sections that support better assessments, safer plans, and stronger communication across the care team.