Short answer: Below are complete SOAP note examples for the disciplines that use the format most — therapy/counseling, nursing, and physical therapy — plus a quick-reference of what changes between fields. Same four sections everywhere (Subjective, Objective, Assessment, Plan); what shifts is what counts as "objective data" and how the plan is phrased. Educational examples for documentation practice — details are fictional, and this is not medical advice.
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SOAP Note Examples: Therapy, Nursing, and Physical Therapy
If you're new to the format itself, start with our SOAP notes guide and template; this page is the example library. Each example is written the way instructors ask to see them: specific, separated, and executable.
Therapy / counseling SOAP note example
S: Client reports "a better week than last," rating mood 6/10 (up from 4/10). States she used the breathing exercise before two work presentations and "got through both without leaving the room." Reports one difficult evening after a phone call with her mother; describes rumination lasting "a couple of hours."
O: On time; groomed appropriately. Engaged throughout; maintained eye contact. Affect brighter than previous session; congruent with reported mood. Completed thought-record homework 4 of 7 days.
A: Progress toward treatment goal #1 (anxiety management in work settings): client independently applied coping skill in two trigger situations. Family-related rumination remains an active stressor; homework adherence improving.
P: Continue weekly CBT. Introduce cognitive-restructuring worksheet targeting family interactions. Homework: thought record daily, plus one behavioral experiment (initiating a boundary-setting statement). Next session in 7 days.
Nursing SOAP note example
S: Patient reports incision pain 4/10, "sharp when I stand up," relieved to 2/10 with prescribed analgesic. Reports passing gas this morning; no nausea. States she slept "in stretches" overnight.
O: Day 2 post-appendectomy. T 37.1°C, BP 118/76, HR 80, RR 16, SpO2 98% RA. Incision clean, dry, intact; no erythema or discharge. Bowel sounds present ×4 quadrants. Ambulated to hallway with standby assist ×1.
A: Recovering as expected post-op day 2; pain controlled on current regimen; early mobility on track. No signs of infection.
P: Continue scheduled analgesia; reassess pain q4h. Encourage ambulation TID. Advance diet as tolerated. Monitor incision each shift; educate patient on wound signs to report. Anticipate discharge planning discussion tomorrow.
Physical therapy SOAP note example
S: Patient reports knee stiffness "mostly in the morning," 3/10 during exercise, no swelling since last visit. Completed home program 5 of 7 days; reports stairs are "easier this week."
O: Left knee flexion 118° (prior 110°), extension full. Quad strength 4+/5. Single-leg balance 22s (prior 15s). Completed 3×10 step-downs with good control, minimal compensation.
A: Steady progress toward ROM and strength goals post-meniscectomy, week 5. Functional carryover evident (stairs). On track for projected discharge at week 8.
P: Progress resistance on leg press; add lateral step-downs. Continue home program with added single-leg balance progression. Re-measure ROM next visit; 2 visits/week × 3 weeks.
What changes between disciplines
| Discipline | "Objective" usually means | Plan emphasis |
|---|---|---|
| Therapy / counseling | Presentation, affect, engagement, homework adherence | Interventions, homework, session cadence |
| Nursing | Vitals, wound/line status, intake/output, mobility | Monitoring schedule, comfort measures, education, discharge prep |
| Physical therapy | ROM degrees, strength grades, functional test scores | Exercise progression, home program, visit frequency |
| Medicine (MD/NP/PA) | Exam findings, labs, imaging | Orders, prescriptions, referrals, follow-up interval |
What makes these examples "good"
Three habits worth copying. Numbers over adjectives: "flexion 118°, prior 110°" beats "improving mobility" — progress you can't measure is progress you can't defend. The S/O wall holds: everything reported stays in S, everything observed in O — even when they describe the same thing (patient says pain is 4/10 = S; grimacing on standing = O). Plans have owners and clocks: every P line answers what, who, and when — "reassess q4h," "next session in 7 days," "re-measure next visit."
Frequently Asked Questions
Are these real patient notes?
No — all examples are fictional, written for documentation training. They model structure and level of detail, not clinical guidance for any real case.
Can I use these SOAP examples as templates?
Yes — copy the section structure and replace the content. The companion guide includes a blank prompt-based template you can reuse for any discipline.
How detailed should the Subjective section be in therapy notes?
Selective, not exhaustive: capture mood/status ratings, notable quotes, and reports relevant to treatment goals. A session transcript is not a note — the note is the filtered, clinically relevant account.
Do nurses always chart in SOAP format?
Not always — many facilities use flowsheets, narrative charting, or DAR (Data, Action, Response). SOAP remains the common teaching format and the default where problem-oriented notes are expected.
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