Free SOAP Note Template

What is a SOAP note?

A SOAP note is the standard progress note format in medical and behavioral health documentation. The acronym stands for Subjective, Objective, Assessment, and Plan — four distinct sections that organize the clinical information captured during a patient or client encounter. SOAP notes are used across all healthcare settings, from primary care and psychiatry to therapy, nursing, physical therapy, and emergency medicine. They became the dominant progress note format because the structure itself enforces clinical reasoning: you document what you heard, what you observed, what it means, and what you are doing about it. Insurance companies, state licensing boards, and medical-legal reviewers expect SOAP notes because they demonstrate that the clinician gathered information systematically, formed a clinical impression, and had a plan.

What's in this template

This free SOAP note template includes all four core sections with clinical prompts to guide documentation:

• Subjective: Chief complaint, history of present illness, relevant past psychiatric or medical history, current medications and allergies, social history, substance use, and patient-reported goals or concerns
• Objective: Clinician observations including vital signs (if applicable), appearance and behavior, affect, speech patterns, thought process and organization, and any relevant findings
• Assessment: Diagnostic impression with DSM-5 coding, differential diagnoses considered, progress toward treatment-plan goals, clinical formulation, and response to current interventions
• Plan: Treatment recommendations, medication or intervention adjustments, patient education provided, follow-up appointments, referrals, and next session focus

The template provides section headers with space for narrative documentation, supporting both brief encounter notes and comprehensive intake assessments.

When to use SOAP format

SOAP notes are appropriate for:

• Initial psychiatric evaluations and diagnostic intakes
• Ongoing therapy or counseling progress notes
• Medical visits where psychiatric or behavioral health assessment is part of care
• Court-ordered or legally mandated evaluations
• Insurance-required documentation where medical-necessity language must be explicit
• Any clinical encounter where you need to document systematic assessment and clinical decision-making

SOAP is particularly useful when you are treating a new condition, changing treatment direction, or need to demonstrate clear clinical reasoning for auditing or supervision purposes.

How to use the template with Scriber

Instead of writing your SOAP note from memory after the session ends, Scriber's AI scribe can generate a draft directly from your session audio. You record the session with consent, Scriber transcribes it and structures the content into SOAP format automatically, and you review and edit the generated note rather than starting from a blank page. This eliminates the reconstruction work — the listening back, the scrolling through notes, the deciding what goes in Subjective versus Objective — while preserving the clinical judgment that only you can provide. Edit the draft for accuracy, add clinical formulation details the AI missed, adjust language to match your style, and sign.

Download (free)

This template is available as a printable PDF and as an editable DOCX file. Download and customize it to match your practice's specific requirements, add your clinic name and logo, and use it as a baseline for your own progress notes.

[Download PDF]

Related templates

Looking for alternative note formats?

• DAP Note Template — Condensed three-section format (Data, Assessment, Plan) for faster documentation
• BIRP Note Template — Behavior, Intervention, Response, Plan format for community mental health and SUD programs