Clinical documentation

SOAP Notes

A free SOAP note builder, worked examples across general practice and allied health, and a clear guide to the Subjective, Objective, Assessment, Plan format. Built for Australian clinicians.

Interactive builder, copy or download Examples by discipline
Build a SOAP note
Free tool

Build a SOAP note

Paste your rough notes or dictation, pick your discipline, and the tool structures them into Subjective, Objective, Assessment and Plan. Review each section, then copy or download. Or fill the sections by hand.

1Enter Your Notes

Do not enter real or identifiable patient information. This is a public teaching tool.

2Review and Edit
3Your SOAP Note

Writing these after every consult? Lyrebird drafts the note from the consult in your style, in any format you use, SOAP, ISBAR or fully customisable.

Try Lyrebird for free
Examples are illustrative teaching content, not clinical advice. Review documentation against your own clinical judgement and local governance before use.
Worked examples

SOAP note examples by discipline

Worked SOAP notes across general practice and allied health, showing how the four sections read in practice. Edit any of them in the builder above.

The format

What is a SOAP note?

A SOAP note is a structured clinical note with four sections. It gives every clinician a consistent way to record an encounter and read someone else's, so nothing important gets lost between visits or between team members.

S Subjective

What the patient reports

The presenting complaint and history in the patient's own words: symptoms, timing, what makes it better or worse, and how it affects them. Their experience, not your interpretation.

O Objective

What you measure and observe

Vital signs, examination findings, observations and results. Facts you can measure or see, recorded without interpretation so anyone reading can follow your reasoning.

A Assessment

Your clinical reasoning

The working diagnosis or problem list, the differentials you considered, and how the subjective and objective findings support your thinking. This is where your judgement shows.

P Plan

What happens next

Investigations, treatment, referrals, patient education, safety-netting and follow-up. Specific enough that the next clinician knows exactly what was decided and why.

Method

How to write a SOAP note

The format is simple. Writing one that is actually useful to the next reader takes a little discipline in each section.

Keep Subjective and Objective separate

The most common error is letting interpretation creep into Subjective or Objective. "Patient anxious" is a judgement. "Patient reports feeling on edge since Monday" is subjective; a measured respiratory rate is objective. Keep the data clean so the Assessment can do the reasoning.

Make the Assessment show your thinking

A diagnosis alone is not an assessment. Name the working diagnosis, the differentials you ruled in or out, and the findings that point to each. This is the section a colleague, an auditor, or you in six months will rely on most.

Write a Plan the next person can act on

Be specific: what was started, what was ordered, what the patient was told, when to review, and what should prompt earlier return. Vague plans create rework and risk.

Common questions

SOAP note FAQs

SOAP stands for Subjective, Objective, Assessment, Plan. The four sections move from what the patient reports, to what you find, to what you think, to what you will do.

Your clinical reasoning: the working diagnosis or problem list, the differentials you considered, and how the subjective and objective findings support your thinking. It is interpretation, not raw data.

Yes. The builder at the top of this page is a free SOAP template you can fill in, copy or download, with prompts and worked examples for general practice, occupational therapy, physiotherapy, speech pathology, nursing and mental health.

Yes. Lyrebird listens to the consult and drafts the SOAP note in your style, including letters, referrals and care plans, integrated with your EMR. The builder here is for writing one by hand or learning the format.

The structured note, written for you

SOAP is one format. Lyrebird writes the note from the consult in your style and your format, SOAP, ISBAR or fully customisable, to a clinical standard you can defend.

Try Lyrebird for free