SOAP Notes Cheat Sheet

Health and mental health professionals write SOAP notes as part of their daily work. These notes help document a client’s condition, track changes over time, and guide treatment decisions. They also support communication among different providers who may work with the same patient. Yet, many students, new clinicians, nurses, residents, and even experienced therapists sometimes struggle to remember what should go into each section of the note.

This SOAP Notes Cheat Sheet provides a simple, step-by-step breakdown of how to write accurate and organized notes every time. You’ll find samples, key tips, and practical examples that can be used immediately in clinical documentation. You can save it digitally, print it for quick reference, or keep it beside you while writing notes during or after a patient session to make the process faster and more confident.

What is a SOAP note

SOAP note is clinical documentation format, used by healthcare providers to record a patient’s symptoms, condition, and treatment plan. It help tell the story of what is happening with the patient, what the clinician observed, what the clinician believes is going on, and what should happen next. Most doctors, nurses, therapists, counselors, and other healthcare workers use SOAP format to document every session or visit.

The word SOAP is an abbreviation made from the first letter of each section in the note:

Letter	Meaning	What It Includes
S	Subjective	What the patient reports in their own words (symptoms, feelings, history, concerns).
O	Objective	What the clinician observes or measures (vital signs, physical exams, tests, behaviors, lab results).
A	Assessment	The clinician’s interpretation of the problem based on S + O (diagnosis, progress, risk level, clinical reasoning).
P	Plan	What will be done next (treatment actions, therapies, medications, follow-up schedule, referrals, safety steps).

SOAP notes makes the communication clear and consistent between different professionals who may treat the same patient. For example, one clinician can review the note and quickly understand the patient’s condition, what work has already been done, and what treatment should continue. SOAP notes are also important for legal and insurance purposes because they create a reliable, written record of care. This helps protect both the patient and the clinician while supporting accurate billing, continuity of care, research, planning, and treatment outcomes.

In short, SOAP notes are a simple and organized way to document patient care so that every session is recorded professionally, clearly, and safely.

Here’s the SOAP Cheat Sheet

Use the short version below when you are in a hurry:

S: Patient reports…
O: Clinician observes…
A: Condition indicates…
P: Next steps include…

Here’s the fast cheat sheet:

Section	Key Prompts	What to Avoid
S	“What do they feel?” “How long?” “How severe?”	Do not add your opinion.
O	“What can I measure or see?”	Do not rely on patient feelings.
A	“What does this information mean?”	Do not repeat data without analysis.
P	“What will happen next?”	Do not leave without clear steps.

S: Subjective Section Cheat Sheet

What to Write

This is the patient’s voice. Include:

• Main complaint (in their words)
• Duration and severity of symptoms
• History of current issue
• Relevant medical/psychological history
• Current medications or lifestyle factors
• Patient’s goals or concerns

Helpful Prompts

• “When did this start?”
• “What makes it better or worse?”
• “How does it affect your daily life?”

Good Example

“Patient states they have had sharp lower back pain for 5 days. Pain worsens when lifting objects. Rates pain 7/10. Reports no previous injury.”

Avoid

• Your interpretation
• Medical terms they did not say

O: Objective Section Cheat Sheet

What to Write

Facts, observations, and measurable data. Include:

• Physical findings (vitals, tests, exams)
• Behavioral observations (mental health)
• Diagnostic results or tools used
• Medications administered in-session

Examples of Objective Data

• BP: 130/85 mmHg
• HR: 95 bpm
• Blood sugar: 185 mg/dL
• Behavior: “Tearful, limited eye contact”

Good Example

“BP 125/80 mmHg. Observed mild swelling in right ankle. Patient walked with slight limp.”

A: Assessment Section Cheat Sheet

What to Write

Your clinical judgment. Combine S + O to give meaning.

• Diagnosis or clinical impression
• Progress or lack of progress
• Response to treatment
• Risks or concerns

Helpful Prompts

• What do the findings suggest?
• Is the patient improving or worsening?
• Does the patient meet diagnostic criteria?

Good Example

“Symptoms suggest acute sprain with moderate inflammation. No signs of fracture. Patient responding slowly to treatment; pain remains moderate.”

P: Plan Section Cheat Sheet

What to Write

What will happen next?

• Medication plan (dose + schedule)
• Recommended therapies or exercises
• Follow-up dates
• Referrals if needed
• Safety plan (for mental health cases)

Helpful Prompts

• “How will this be treated?”
• “What should the patient do next?”
• “When is the next visit?”

Good Example

“Recommend ice compress 3× daily for 15 minutes. Start NSAIDs as prescribed. Follow-up in 7 days.”

Full SOAP Notes Sample

Medical Example

S: Patient reports frequent headaches for 2 weeks. Location mainly forehead. Pain level 6/10. Worsens after long screen time.
O: BP 118/78. Pupils normal. No fever. Reports relief after ibuprofen.
A: Likely tension headaches related to prolonged digital exposure. No infection suspected.
P: Recommend limited screen use, hydration, warm compress, ibuprofen as needed. Follow-up in 1 week.

Mental Health Example

S: Patient states they are “feeling overwhelmed and sad most days.” Sleep difficulty for 2 weeks. Rates mood 3/10.
O: Tearful, low tone, minimal eye contact. No suicidal thoughts reported.
A: Symptoms consistent with mild depressive episode. No immediate safety risk.
P: Begin CBT once weekly. Teach breathing exercises. Encourage sleep schedule. Review progress in next session.

Best Tips for Writing SOAP Notes

1. Keep it clear and short

What it means: Your SOAP note should be easy to read and quick to understand. Another clinician should be able to scan it in a few seconds and know what is happening with the patient.

How to do it:

• Use simple words and short sentences.
  • Instead of: “The patient exhibits considerable ambulation difficulties.”
  • Write: “The patient has trouble walking.”
• Focus on important information only:
  • What brought the patient here?
  • What changed since the last visit?
  • What did you observe today?
  • What is your impression and plan?

Good example (clear and short):

“Patient reports chest tightness for 3 days, worse on exertion. No shortness of breath at rest.”

Bad example (too long and unclear):

“The client mentioned a variety of sensations over the past week, including some discomfort in the chest that they think may or may not be related to stress, but they are not sure…”

The first one is faster to read and easier to understand.

2. Use numbers whenever possible

What it means: Numbers make your note more objective, clear, and measurable. They help show change over time.

Examples of useful numbers:

• Pain scale: “Pain 7/10” instead of “severe pain.”
• Vital signs: BP 130/85, HR 94 bpm, Temp 37.8°C.
• Frequency: “Panic attacks 3 times this week” instead of “often.”
• Duration: “Symptoms for 2 weeks” instead of “for a while.”
• Session details: “Session length 50 minutes.”

Why it matters:

• Numbers show progress or no progress:
  • Visit 1: Pain 8/10
  • Visit 2: Pain 5/10
    This clearly shows improvement.
• They reduce confusion. Different people may understand words like “mild” or “severe” differently. Numbers are more precise.

Example:

• Better:“Patient reports anxiety 6/10 today (was 8/10 last week). Slept 5 hours per night on average.”
• Worse:“Patient feels very anxious and is not sleeping well.”

3. Avoid assumptions in “S” and “O”

What it means: The Subjective (S) and Objective (O) sections should contain facts, not guesses.

• S (Subjective): What the patient says.
• O (Objective): What you see, measure, or test.

Your opinions, diagnoses, and interpretations belong in A (Assessment), not in S or O.

Examples of assumptions to avoid:

• In S:
  Don’t write: “Patient is exaggerating pain.”
  Instead write: “Patient reports pain 9/10, describes as ‘unbearable’.”
• In O:
  Don’t write: “Patient is likely depressed.”
  Instead write: “Patient appears tearful, slow speech, limited eye contact.”

Why this is important:

• Keeps your note professional and defensible.
• Makes it easier for others to see the difference between:
  • What happened (S and O)
  • What you think it means (A)

Good structure:

• S: “Patient says…”
• O: “Clinician observed…”
• A: “These findings are consistent with…”
• P: “Will do…”

4. Make every “P” actionable

What it means:

The Plan (P) section should always answer the question: What happens next?

Anyone reading the note should know exactly what you and the patient will do after this visit.

A strong Plan section includes:

• Treatments or interventions (medication, therapy type, exercises)
• Frequency and duration (e.g., once a week, for 6 sessions)
• Homework or recommendations for the patient
• Referrals to other professionals
• Safety steps (if needed)
• Next appointment or follow-up

Examples of actionable “P”:

“Begin CBT once weekly for 8 weeks. Teach grounding exercise today; ask patient to practice twice daily. Follow-up in 1 week.”

“Increase sertraline from 50 mg to 75 mg daily. Monitor side effects. Review in 2 weeks.”

Non-actionable “P” (what to avoid):

• “Will continue treatment.” (Too vague)
• “Follow-up later.” (When? How?)

Make it specific:

• What: “Start breathing exercise.”
• How often: “Practice 5 minutes, 3 times per day.”
• When: “Next session in 7 days.”

A Quick Summary of All Tips

• Clear and short:
  Use simple words and focus only on important details.
• Use numbers:
  Record pain, vitals, frequency, duration, and changes with numbers.
• No assumptions in S and O:
  S = patient’s words, O = your observations and measurements. Keep your opinions for A.
• Actionable P:
  Every Plan must clearly show what you and the patient will do next.

How Skriber Helps You Write Better SOAP Notes

Writing detailed and accurate SOAP notes can take a lot of time, especially when seeing many patients in a busy clinic. Skriber is an AI-powered medical and mental health documentation assistant designed to make this process faster and more accurate. Instead of spending extra minutes typing long notes after each session, clinicians can record a visit or dictate key points, and Skriber automatically organizes everything into the correct SOAP structure.

Skriber does more than just transcribe voice notes. It understands clinical language, recognizes professional terminology, and arranges findings into Subjective, Objective, Assessment, and Plan with high precision. It can capture symptoms in the patient’s own words for the Subjective section, pull factual observations for Objective, summarize clinical impressions for Assessment, and clearly write treatment actions for the Plan. This reduces errors and saves valuable time, while still allowing the clinician to review and edit the note as needed.

For students and new clinicians, Skriber can be a great learning tool because it demonstrates how structured, professional SOAP notes should look. For experienced practitioners, it offers speed, consistency, and support during busy schedules. It keeps documentation organized, reduces burnout, and helps providers spend more time with patients instead of paperwork. By combining professional knowledge with advanced AI, Skriber makes writing SOAP notes easier, faster, and more reliable for real clinical settings.

Final Thoughts

A well-written SOAP note is accurate, professional, and clear, without being overly long. When clinicians document information in an organized way, they support safer patient care, clearer communication, and better treatment decisions. A strong SOAP note also serves as reliable legal documentation and supports insurance billing, showing exactly what happened during a visit and why certain clinical choices were made.

By using this cheat sheet, you can write consistent and high-quality notes with less stress and greater confidence. Whether you are a student learning the basics or an experienced clinician trying to save time, having a structured guide helps you stay focused on what truly matters: capturing the patient’s story, your professional observations, and the plan that will help them move forward. Clear documentation not only protects the provider—it ultimately improves outcomes for the patient and strengthens the overall quality of care.