SOAP Note Example: A Med Student's Guide

Are you looking for a SOAP note example that’ll show you how to complete your notes in a professional manner? If so, we can help! This post breaks down every section of a SOAP progress note and provides you with an example of each. At the end, we stitch them all together into one complete, ready-to-submit note for Mr. Gerald Henderson, a fictional 67-year-old with heart failure, now on hospital day two and starting to look a lot better.

To make sure we’re all starting on the same page, let’s first get into a bit of background on what SOAP notes are and when you use them. That’ll put the rest of our discussion into the right context.

Let’s begin.

What is a SOAP Note?

💡 The daily SOAP (subjective, objective, assessment, plan) progress note is the document you’ll write every day for every patient you’re following on an inpatient rotation.

A lot of students treat the note like a data dump, vitals here, labs there, and plans copied from the day before. But once you understand what each section is for and give them the attention they require, progress notes become faster, sharper, and genuinely useful for your team.

First things first: the SOAP progress note is not the H&P!

This is the most important distinction to internalize before you write a single word.

⭐ The history and physical (H&P) is written once on admission per patient. It’s meant to cover the full history, detailed physical exam, review of systems, past medical and surgical history, medications, allergies, social history, family history, labs, and the initial plan.

⭐ The SOAP progress note is written each day thereafter to answer what has changed since yesterday, and what the team needs to do about it.

The table below clarifies a SOAP progress note vs an H&P:

Attribute	The H&P (History & Physical)	The SOAP Progress Note
Purpose	To comprehensively document a brand-new admission or consultation	To document the 24-hour interval updates of an existing patient on wards. Overnight events, how problems are managed, any consult updates are listed here.
Length	3 to 5 pages (dense and more extensive as it includes the patient’s entire relevant medical history)	1-2 pages focused on this hospital admission and what is actively being managed
Frequency	Once at the start of the patient’s admission	Daily
Core Focus	Chronic conditions, all relevant history (family, surgical, medical, psychiatric, etc. histories), full review of systems	Acute clinical changes, active lab trends, and today’s operational plan

An analogy I learned in med school: think of the H&P as a patient’s complete medical biography 📕, and the SOAP note as the daily newspaper. 📰 Your attending doesn’t want to re-hear a patient’s childhood tonsillectomy on their hospital day 4 stay!

They want to know: what’s changed since yesterday, what does the data show right now, and what are we doing about it today?

In the case of our fictional patient Mr. Henderson, the team already knows why he was admitted due to what’s in the H&P before you write the SOAP note—so you don’t need to reestablish that. The point of the progress note is to pick up where yesterday left off!

When You’ll Use SOAP Progress Notes

You’ll write SOAP-format progress notes in most inpatient clinical environments you rotate through including inpatient medicine, surgery, pediatrics, OB, and psychiatry. You’ll hear attendings frame note quality in terms of billing or compliance.

But the more important reason to write them is that other people (the overnight resident, the physical therapist, or anyone on the following team) will make clinical decisions based on it.

Breaking Down Our SOAP Note Example: Mr. Henderson

If you read our post on how to give a SOAP note presentation, you’ll recall that Mr. Henderson is a 67-year-old male with a history of heart failure with reduced ejection fraction (HFrEF, EF 35%), hypertension, type 2 diabetes, and chronic kidney disease stage 3b (baseline creatinine 1.2). He was admitted two days ago with acute decompensated heart failure—his precipitants were dietary sodium indiscretion and running out of his furosemide four days before admission.

On admission: bilateral crackles, JVD, 2+ pitting edema to the knees, SpO₂ 92% on room air, BNP 1,840, creatinine 1.6, BP 158/92, weight 98 kg (8 lbs above his estimated dry weight of ~90 kg). We started IV furosemide 80 mg BID.

Today is hospital day 2. You pre-rounded him at 5:45 a.m. and found that he’s doing better.

With this information in hand, it’s time to write his SOAP note so there’s a record of what’s changed and what is being done about it.

But what, exactly, will you put in the note?

Before going over the complete SOAP note example, let’s break it down section by section:

The Header

There are different styles and templates of progress notes so here we’ll go over one way to do it. Every progress note benefits from a clean header before the SOAP content begins. This helps orient the reader.

For example, the night resident opening the chart at 2 a.m. needs to know immediately who wrote this note, when, and for what patient. Some EMRs may automatically generate certain items so be cognizant of that.

What belongs in the header:

Patient name and MRN
Date and time the note was written
Note type, your role, and your co-signer
Hospital day number
Admission diagnosis and status

Header for Mr. Henderson:

Patient: Gerald Henderson | MRN: [XXXXXXX] Date/Time: [Today’s Date], 06:10 Note Type: Internal Medicine Progress Note — MS3 (to be co-signed by [Resident Name], PGY-2) Hospital Day 2 Admission Diagnosis: Acute Decompensated Heart Failure, Stable.

The header should take about 10 seconds to read. It orients the reader to what’s happening with a case and allows them to move on.

S — Subjective

The subjective section captures what the patient tells you, their symptoms, their experience, and how they feel today. Your interpretation doesn’t belong here. Your exam findings don’t belong here. Labs and vitals definitely don’t belong here. Those come later.

Include the following:

Overall trajectory: better, worse, or about the same
Changes in the primary complaint overnight
Any new symptoms that emerged since your last note
Sleep, appetite, pain level, mood (Some are more important than others depending on the reason for admission.)
Anything the patient specifically asked about or is worried about
For a heart failure patient: symptoms that signal under-diuresis (breathless, swelling, orthopnea etc) or over-diuresis (lightheaded, muscle cramps, thirsty, decreased urine output).

Leave out:

Items from the H&P
Stable chronic symptoms that aren’t active issues today

Keep it brief, two or three sentences is often enough. The subjective section of a progress note should never be the longest section in the note.

Subjective for Mr. Henderson:

Patient reports feeling “much better” than yesterday, particularly, he notes his “Breathing has improved and he was able to sleep without waking up short of breath.” He denies chest pain, lightheadedness, palpitations, or muscle cramps and states his appetite is returning. He has no new complaints and mentions he is eager to go home.

O — Objective

The objective section is what you directly observe and measure. Vitals, intake and output, physical exam findings, laboratory results, imaging, telemetry, measurable data that directs your treatment plan for the patient.

This section should be organized and readable at a glance. A busy resident should be able to read it in 30 seconds and find what he/she needs from it.

Vitals

Lead with the most recent set of vitals. Always include the weight in a patient where fluid status matters. And try to show a trend when possible.

Example:

Vitals (0600): T 36.9°C | HR 82 | BP 138/84 | RR 16 | SpO₂ 97% on room air Weight: 95.4 kg (↓ 2.6 kg from yesterday; ↓ 5.6 kg from admission weight of 98 kg; estimated dry weight 90 kg)

In a heart failure patient, his weight tells your team exactly where things stand at a glance.

Intake and Output

For any patient where fluid balance is actively managed such as heart failure, AKI, sepsis, or post-operative include the I&Os. Your team needs to know whether the diuresis is working.

Example:

I&O (past 24 hrs): Input 1,540 mL | Output 3,180 mL | Net: −1,640 mL Cumulative net since admission: −3,200 mL

Negative 1.5 liters in 24 hours with a cumulative negative 3.2 liters.

Physical Exam

Unlike the H&P, your SOAP note exam does not need to cover every organ system. Cover the systems relevant to the active problems, note any new findings, and compare to prior days if appropriate.

Example:

General: Alert, in no acute distress. Sitting comfortably in bed. Breathing noticeably easier than yesterday.

Cardiovascular: RRR. S1/S2 present. No JVD (resolved since admission). Peripheral pulses 2+ bilaterally.

Pulmonary: Clear to auscultation bilaterally. Bibasilar crackles resolved (present on admission and yesterday). No wheezing.

Extremities: Bilateral LE edema improved to 1+ at the ankles (was 2+ to knees on admission). No erythema or calf tenderness.

Notice what’s absent: no neuro exam, no HEENT. Those systems aren’t relevant to today’s active management.

Labs and Imaging

Group labs logically, flag the abnormal ones, and trend. Don’t simply list results in the order they appear in your EMR.

Example:

A.M. Labs:

Test	Today (Day 2)	Admission	Trend
BNP	580 pg/mL	1,840 pg/mL	↓ Responding to treatment
Creatinine	1.4 mg/dL	1.6 (baseline: 1.2)	↓ Improving
BUN	24 mg/dL	28 mg/dL	↓ Improving
Sodium	136 mEq/L	134 mEq/L	↑ Normalizing
Potassium	3.6 mEq/L	4.1 mEq/L	↓ Trending down —replete and monitor
Glucose	138 mg/dL	148 mg/dL	↓ Slightly improved

CBC unchanged from admission. No new imaging or studies today.

A — Assessment

The assessment is the synthesis and the section most students struggle with. You need to go beyond copying down labs or storytelling what the patient reports. If the subjective is the patient’s story and your objective is the data, the assessment is where you explain it all.

A good assessment does the following:

States the patient’s clinical trajectory (improving, worsening, stable)
Explains why things are moving in that direction
Flags any emerging concerns or things that need to be watched
Dovetails with the plan (The assessment and plan should feel like a continuous thought.)

Assessment for Mr. Henderson:

Mr. Henderson is a 67-year-old with HFrEF, admitted for acute decompensated HF, now on hospital day two with a favorable response to IV diuresis (down 3.2L since admission). Clinically he is improved: orthopnea has resolved, bibasilar crackles have cleared as has his JVD. He has net diuresed 3.2 liters since admission and is down 5.6 kg, trending toward his estimated dry weight of 90 kg. BNP has dropped to 580.

His prerenal AKI is tracking in the right direction, creatinine 1.6 → 1.4 consistent with improved forward flow as the heart failure is treated. One emerging concern: potassium is trending down to 3.6 with aggressive diuresis and warrants oral repletion today and close monitoring tomorrow. Blood pressure has improved to 138/84.

Overall, this patient is on a clear trajectory toward discharge.

P — Plan

The plan is where assessment becomes action. It should be organized by problem. Every problem gets its own management bullets: what you’re continuing, what you’re changing, what you’re monitoring, what you’re ordering, and who you’re looping in.

Structure for each problem:

Problem [#]: [Diagnosis] — [One-Word Status: Improving/Stable/Worsening/New]

What you’re continuing and why
What you’re changing and why
What labs, vitals, or clinical parameters you’re watching
Consults, patient education, and next steps
Disposition if relevant
Any if/then statements to look out for

Plan for Mr. Henderson:

Problem 1: Acute Decompensated Heart Failure — Improving

Continue IV furosemide 80 mg BID today; reassess volume status tomorrow a.m. before rounds.
Ease up on I&O net goal to −1.0 to −1.5 L today — patient is approaching dry weight, avoid over-diuresis.
If euvolemic tomorrow a.m. (weight near 90 kg, clear lungs, resolved edema, no orthopnea): transition to oral furosemide 40 mg PO BID — increased from prior home dose of 40 mg, which was insufficient.
Continue fluid restriction 1.5 L/day and strict low-sodium diet.
Continue daily weights and strict I&Os.
Repeat BMP tomorrow a.m., look specifically for Cr and potassium levels.
Arrange outpatient cardiology follow-up within seven days of discharge per HF readmission prevention protocol.
Patient education today: reviewed daily weight log (call PCPfor >2 lb gain in 24 hours or >5 lb in 1 week), sodium restriction, and the importance of never running out of furosemide, patient verbalized understanding.

Problem 2: Prerenal AKI on CKD — Improving

Creatinine trending down 1.6 → 1.4; consistent with improved cardiac output from diuresis.
Continue to hold metformin (risk of lactic acidosis in setting of AKI); resume at discharge if creatinine back to baseline of 1.2.
Monitor with a.m. BMP tomorrow; no nephrology consult needed at this time, reassess if creatinine fails to continue improving.

Oral potassium chloride 40 mEq x1 this a.m.
Recheck potassium with a.m. BMP tomorrow.
If K+ < 3.5 tomorrow: repeat oral KCl 40 mEq and recheck in 4 hours.
If K+ < 3.0 or symptomatic (cramping, weakness, palpitations): IV repletion and consider reducing diuresis intensity.
Continue telemetry monitoring given electrolyte shifts and underlying cardiac history.

Problem 4: Hypertension — Improving

BP improved to 138/84 from 158/92 on admission, attributable to diuresis and improved volume status.
Continue home lisinopril 10 mg PO daily; no additional antihypertensives at this time.
Reassess blood pressure trajectory at outpatient follow-up; consider uptitration of lisinopril if elevated once patient is at true dry weight.

Problem 5: Type 2 Diabetes — Stable (Metformin on Hold)

Blood glucose QID with sliding scale insulin coverage; a.m. glucose 138, acceptable.
Metformin held during admission plan to resume at discharge when creatinine at baseline.
Outpatient PCP to address HbA1c of 7.9% and ongoing glycemic management at follow-up visit.

Disposition: Target Discharge Hospital Day 3, Contingent on:

Clinical euvolemia confirmed on a.m. exam and weight.
Creatinine trending toward baseline (1.2).
Potassium ≥ 3.5 mEq/L on a.m. labs.
Patient tolerating transition to oral furosemide.
Discharge education complete and prescriptions reconciled — new furosemide 40 mg PO bid to be prescribed (up from 40 mg qd).

The Complete SOAP Note Example

Here it is. Every section we built above, assembled into one clean, complete, co-signable SOAP progress note. This is your template.

INTERNAL MEDICINE PROGRESS NOTE — MEDICAL STUDENT MS3

To be co-signed by [Resident Name],

Patient: Gerald Henderson | MRN: [XXXXXXX] Date/Time: [Today’s Date], 06:10 Hospital Day 2 | Admission Diagnosis: Acute Decompensated Heart Failure

S — SUBJECTIVE

Patient reports feeling “much better” than yesterday, particularly, he notes his “Breathing has improved and he was able to sleep without waking up short of breath.” He denies chest pain, lightheadedness, palpitations, or muscle cramps and states his appetite is returning. He has no new complaints and mentions he is eager to go home.

O — OBJECTIVE

Vitals (0600): T 36.9°C | HR 82 | BP 138/84 | RR 16 | SpO₂ 97% on room air Weight: 95.4 kg (↓ 2.6 kg from yesterday; ↓ 5.6 kg from admission weight of 98 kg; estimated dry weight ~90 kg)

Intake and Output (past 24 hours): Input 1,540 mL | Output 3,180 mL | Net: −1,640 mL Cumulative net since admission: −3,200 mL

Physical Exam:

General: Alert, in no acute distress. Sitting comfortably in bed, breathing is noticeably easier than it was yesterday.

Cardiovascular: RRR. S1/S2 present. No JVD (resolved since admission). Peripheral pulses 2+ bilaterally.

Pulmonary: Clear to auscultation bilaterally. Bibasilar crackles resolved (present on admission and yesterday). No wheezing.

Extremities: Bilateral LE edema improved to 1+ at the ankles (was 2+ to knees on admission). No erythema or calf tenderness.

Labs: (note a lot of labs will automatically be input from your hospital EMR) if that is the case, bold or highlight the ones to focus on.

Test	Today (HD2)	Admission	Trend
BNP	580 pg/mL	1,840 pg/mL	↓ Responding to treatment
Creatinine	1.4 mg/dL	1.6 (baseline: 1.2)	↓ Improving
BUN	24 mg/dL	28 mg/dL	↓ Improving
Sodium	136 mEq/L	134 mEq/L	↑ Normalizing
Potassium	3.6 mEq/L	4.1 mEq/L	↓ Trending down — monitor
Glucose	138 mg/dL	148 mg/dL	↓ Slightly improved

CBC unchanged from admission. No new imaging or additional studies today.

A — ASSESSMENT

Mr. Henderson is a 67-year-old with HFrEF, admitted for acute decompensated HF, now on hospital day 2 with a favorable response to IV diuresis (down 3.2L since admission). Clinically , he is improved, volume status and symptoms are resolved, his creatinine is downtrending. We should replete and monitor his potassium. Overall, this patient is on a clear trajectory toward discharge.

P — PLAN

Problem 1: Acute Decompensated Heart Failure — Improving

Continue IV furosemide 80 mg BID today; reassess volume status tomorrow a.m. before rounds.
Ease up on I&O net goal to −1.0 to −1.5 L today — patient is approaching dry weight, avoid over-diuresis.
If euvolemic tomorrow a.m. (weight near 90 kg, clear lungs, resolved edema, no orthopnea): transition to oral furosemide 40 mg PO BID — increased from prior home dose of 40 mg, which was insufficient.
Continue fluid restriction 1.5 L/day and strict low-sodium diet.
Continue daily weights and strict I&Os.
Repeat BMP tomorrow a.m., look specifically for Cr and potassium levels.
Arrange outpatient cardiology follow-up within seven days of discharge per HF readmission prevention protocol.
Patient education today: reviewed daily weight log (call PCP for >2 lb gain in 24 hours or >5 lb in one week), sodium restriction, and the importance of never running out of furosemide, patient verbalized understanding.

Problem 2: Prerenal AKI on CKD — Improving

Creatinine trending down 1.6 → 1.4; consistent with improved cardiac output from diuresis.
Continue to hold metformin (risk of lactic acidosis in setting of AKI); resume at discharge if creatinine back to baseline of 1.2.
Monitor with a.m. BMP tomorrow; no nephrology consult needed at this time, reassess if creatinine fails to continue improving.

Oral potassium chloride 40 mEq x1 this a.m.
Recheck potassium with a.m. BMP tomorrow.
If K+ < 3.5 tomorrow: repeat oral KCl 40 mEq and recheck in four hours.
If K+ < 3.0 or symptomatic (cramping, weakness, palpitations): IV repletion and consider reducing diuresis intensity.
Continue telemetry monitoring given electrolyte shifts and underlying cardiac history.

Problem 4: Hypertension — Improving

BP improved to 138/84 from 158/92 on admission, attributable to diuresis and improved volume status.
Continue home lisinopril 10 mg PO daily; no additional antihypertensives at this time.
Reassess blood pressure trajectory at outpatient follow-up; consider uptitration of lisinopril if elevated once patient is at true dry weight.

Problem 5: Type 2 Diabetes — Stable (Metformin on Hold)

Blood glucose QID with sliding scale insulin coverage; a.m. glucose 138, acceptable.
Metformin held during admission plan to resume at discharge when creatinine at baseline.
Outpatient PCP to address HbA1c of 7.9% and ongoing glycemic management at follow-up visit.

Disposition: Target Discharge Hospital Day 3, Contingent on:

Clinical euvolemia confirmed on a.m. exam and weight.
Creatinine trending toward baseline (1.2).
Potassium ≥ 3.5 mEq/L on a.m. labs.
Patient tolerating transition to oral furosemide.
Discharge education complete and prescriptions reconciled — new furosemide 40 mg PO bid to be prescribed (up from 40 mg qd).

Conclusion

As our SOAP note example indicates, Mr. Henderson is improving—and it was documented in a way that any clinician such as the night float resident, the weekend coverage, or the nursing staff can follow and act on.

That’s the whole point of a SOAP progress note. It’s to show who saw the patient, interpreted the data, and what they thought should come next.

And one last thing: your note outlasts your rotation! Long after you’ve moved to the next service and forgotten what Mr. Henderson’s potassium was on hospital day two, your words are still in his chart. Remember that, and be sure the work you put into the note is something you’re prepared to stand by. Follow the tips we’ve provided here and it will be!

And for more (free!) tips for clinical rotations, check out these other posts:

A Step-by-Step Guide to Writing SOAP Notes + a Completed SOAP Note Example

What is a SOAP Note?