SOAP Note Generator

Generate SOAP notes for tracking and documenting client progress.

Shorthand notes or a description of the case

0/50000

Additional Instructions

0/2500

It will help the AI to generate a more accurate note.

Use advanced AI model? Best ResultsEnable this feature to leverage our cutting-edge AI technology for superior performance and more accurate results! Powered by GPT-4.

Get access to more features by upgrading your plan.

10x smarter AI
More customization options

Unlimited generations
Faster generation

Upgrade

outputs

language

HIPAA Compliant: Our platform is fully HIPAA compliant, ensuring your healthcare data is protected with the highest security standards.

Save hours of your time

Harness AI to dramatically speed up your content creation

Our AI-powered tool can generate high-quality, tailored content in seconds, not hours. Boost your productivity and focus on what really matters.

Use Cases

Discover how this template can be used in various scenarios

Healthcare Providers

Documenting patient encounters with structured SOAP notes that meet clinical documentation standards.

Mental Health Professionals

Creating detailed therapy session notes while maintaining client confidentiality and treatment progress.

Physical Therapists

Recording patient assessments, treatments, and progress using the SOAP format for rehabilitation services.

Nurse Practitioners

Maintaining comprehensive patient records with organized SOAP documentation for primary care visits.

Medical Students

Learning and practicing proper clinical documentation through structured SOAP note writing.

Occupational Therapists

Tracking client interventions and outcomes with detailed SOAP notes for therapy sessions.

How to use the SOAP Note Generator

1Create a free account
2Once you've logged in, find the SOAP Note Generator template amongst our 200+ templates.
3Fill out Shorthand notes or a description of the case. For example: Client: male, Age: 25, Diagnosis: Anxiety. His anxiety has been increasing over the past few weeks. Social: lives with his parents, works as a software engineer. Medical: no significant medical history. Goals: to reduce anxiety and improve sleep.
4Fill out Additional Instructions. For example: Make the note concise and to the point
5Enable the 'Use advanced AI model?' toggle to leverage our cutting-edge AI technology for superior performance and more accurate results! Powered by GPT-4.
6Click on Generate and get tons of ideas, generated by A.I. 🤖

Try it yourself for free

SOAP Note Templates & Examples

INPUT
Client: male, Age: 25, Diagnosis: Anxiety. His anxiety has been increasing over the past few weeks. Social: lives with his parents, works as a software engineer. Medical: no significant medical history. Goals: to reduce anxiety and improve sleep.
OUTPUT
Subjective:
The client is a 25-year-old male software engineer who reports a gradual increase in anxiety levels over the past few weeks. The client mentions increased worry and nervousness that is significantly impacting his sleep quality. He has expressed the desire to reduce his anxiety levels and improve his sleep. Currently living with his parents and does not report any significant social stressors.

Objective:
Physically, the client appears restless and demonstrates signs of fatigue, likely due to disrupted sleep. No significant weight change is noticed. No other physical symptoms have been reported.

Assessment:
The client's symptoms, including increased worry, nervousness, and disrupted sleep, are consistent with an anxiety disorder. The gradual increase in symptoms over the last few weeks signifies that the anxiety is becoming progressively severe. No other medical condition seems present that could explain the symptoms.

Plan:
Discuss potential therapy strategies for anxiety management such as cognitive-behavioral therapy (CBT) and Mindfulness techniques. Depending upon the severity of the condition, consider the controlled use of anxiolytics. Sleep hygiene practices should also be emphasized to help improve sleep quality. Suggest regular exercise and a balanced diet to supplement therapy. Follow-up in two weeks to assess progress and adjust therapeutic strategies if necessary. Encourage the client to seek immediate help if symptoms worsen or if new symptoms emerge.
INPUT
CC: 32F, persistent sadness, ↓ motivation, sleep issues x 6 months. HPI: Mood ↓ post-relationship breakup. Frequent crying, hopelessness, ↓ interest in past activities. No SI, but passive thoughts of not waking. ↓ Concentration, social withdrawal.
Past MH: GAD in college, no meds. Counseling x 6 months post-trauma (5 yrs ago). Meds: No psych meds. Multivitamins, OTC sleep aids occasionally. Social: Living alone post-breakup. Graphic designer. ↓ Social interactions, ↑ alcohol, no drugs. Family: Mother: MDD. Uncle: Bipolar. No suicide/psychosis history. Goals: Regain normalcy, ↑ sleep quality, coping strategies.
OUTPUT
SOAP Note:

Subjective:
32-year-old female patient presents with persistent sadness, decreased motivation, and sleep disturbances for the past 6 months. The precipitating event appears to be the end of a significant relationship. The patient reports frequent episodes of crying, feelings of hopelessness, and decreased interest in activities she previously enjoyed. She denies any active suicidal ideation but admits to having passive thoughts about not waking up. She also reports decreased concentration and social withdrawal. The patient has a history of generalized anxiety disorder (GAD) in college, for which she did not take any medications. She had counseling for 6 months following a traumatic event 5 years ago. Currently, the patient is not taking any psychiatric medications but takes multivitamins and over-the-counter sleep aids occasionally. The patient is a graphic designer and has been living alone since her breakup. She reports decreased social interactions and increased alcohol consumption. There is no history of drug abuse. Her mother has a history of major depressive disorder (MDD), and her uncle has bipolar disorder. There is no history of suicide or psychosis in the family. The patient's goals include regaining a sense of normalcy, improving sleep quality, and developing coping strategies.

Objective:
Upon examination, the patient appears sad and withdrawn. There are no obvious signs of self-harm or neglect. The patient's speech is coherent, and she is alert and oriented to place, person, and time. There is evidence of decreased psychomotor activity.

Assessment:
Major depressive disorder, probable, based on the patient's symptoms of persistent sadness, decreased motivation, sleep disturbances, frequent crying, feelings of hopelessness, and decreased interest in previously enjoyed activities. The patient's symptoms have persisted for over 6 months post-relationship breakup and represent a significant change from her previous level of functioning.

Plan:
- Start the patient on a selective serotonin reuptake inhibitor (SSRI) to help manage her symptoms of major depression.
- Refer the patient to a psychotherapist for cognitive-behavioral therapy (CBT) to help her develop coping strategies.
- Schedule a follow-up appointment in 2 weeks to monitor the patient's response to the SSRI and to assess the need for any modifications to her treatment plan.
- Encourage the patient to limit her alcohol intake as it can worsen depression and interfere with the effectiveness of her treatment.
- Recommend the patient to join a support group to help improve her social interactions and provide a forum for discussing her feelings and experiences.
- Educate the patient about the importance of regular sleep and provide advice on sleep hygiene.
- Monitor the patient closely for any signs of suicidal ideation or self-harm.
INPUT
Male (34 year old) reports persistent feelings of sadness and hopelessness for the past 6 months. Patient describes mood as 'down' and 'heavy'.
OUTPUT
SOAP Note:

S: Subjective -
The patient is a 34-year-old male who reports persistent feelings of sadness and hopelessness for the past 6 months. He describes his mood as consistently 'down' and 'heavy'. He denies any recent traumatic life events or abuse of alcohol or drugs. He reports difficulties concentrating and sleeping, reduced energy, and decreased interest in activities he used to enjoy.

O: Objective -
Patient appears tired, disheveled, and displays poor eye contact. His speech is slow and soft. On the Beck Depression Inventory, patient scored 32 (moderate to severe depression).

A: Assessment -
Based on the presenting symptoms and patient's reported experiences over the past six months, this appears to be a case of Major Depressive Disorder (MDD), current episode severe without psychotic features, as per DSM-5 criteria.

P: Plan -
- Begin a regimen of an SSRI antidepressant, starting with a low dose and increasing as tolerated.
- Provide the patient with psychoeducational materials on depression, its symptoms, and management strategies.
- Refer the patient to a psychotherapist for Cognitive Behaviour Therapy (CBT), which has been shown to be effective in managing MDD.
- Encourage the patient to practice self-care, such as regular exercise, a healthy diet, and adequate sleep.
- Schedule a follow-up appointment within two weeks to monitor medication effects and side effects.
- Advise the patient to reach out immediately if thoughts of self-harm or suicide arise, providing him with emergency contact numbers.

Try it yourself for free

Frequently asked questions

: A SOAP note is a systematic and standardized method of documentation employed by healthcare providers to write out notes in a patient's chart. The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. The "Subjective" component describes the patient's condition in the form of their symptoms, which are reported by the patient. The "Objective" part details the clinical evidence or facts observed by the healthcare provider. "Assessment" is the diagnosis or condition the patient has, and the "Plan" is the course of action determined by the healthcare provider. SOAP notes are used along with other common formats, such as the admission note, and are integral to maintaining comprehensive and efficient patient records.
: SOAP notes are commonly used by healthcare providers across various fields including Physical Therapy, Occupational Therapy, Speech-Language Pathology (SLP), Mental Health, Nursing, Podiatry, Veterinary, Massage Therapy, Chiropractic, Acupuncture and Pharmacy.
: SOAP notes offer numerous benefits including: standardized documentation that improves communication between healthcare providers, clear organization of patient information, better tracking of patient progress over time, compliance with legal and insurance requirements, and efficient clinical decision-making. They also help maintain continuity of care when multiple providers are involved in treatment.
: To write an effective SOAP note: 1) Under Subjective, document the patient's reported symptoms, concerns, and progress, 2) For Objective, record measurable observations, vital signs, and test results, 3) In Assessment, provide your professional analysis and diagnosis, 4) For Plan, detail the treatment strategy and next steps. Be clear, concise, and specific while avoiding subjective language. Include relevant details but omit unnecessary information.
: A good SOAP note generator should provide structured templates, maintain HIPAA compliance, offer customization options, ensure accuracy and completeness, save time through automation, and be user-friendly. It should help healthcare providers focus on patient care while maintaining thorough documentation. Easy-Peasy.AI's SOAP note generator includes all these features plus AI-powered assistance for more efficient note creation.
: While SOAP notes are not universally mandated, they are widely accepted as a standard format for medical documentation. Many healthcare facilities require SOAP notes for their clarity and comprehensiveness. They help meet legal requirements for documentation, support insurance claims, and facilitate quality patient care. Using a standardized format like SOAP notes also helps protect healthcare providers in case of legal issues.
: To use the SOAP Note Generator, simply enter your shorthand notes or case description including relevant details like patient demographics, symptoms, observations, and treatment goals. You can also add specific instructions to customize the output. The AI will then generate a properly formatted SOAP note based on your input.
: Include key details such as: patient demographics (age, gender), chief complaint or diagnosis, relevant history, current symptoms or concerns, objective observations, social/medical background, and treatment goals. The more relevant information you provide, the more comprehensive and accurate your generated SOAP note will be.
: Yes, you can customize your SOAP notes by providing additional instructions in the "Additional Instructions" field. You can specify preferences for length, detail level, focus areas, or any special requirements. Using our advanced AI model (GPT-4) also provides enhanced customization capabilities.
: The accuracy of generated SOAP notes depends on the quality and completeness of your input. Our AI is trained on proper medical documentation standards but should be reviewed and edited by qualified healthcare professionals before being used officially. The advanced AI model option provides improved accuracy and more nuanced documentation.
: The SOAP Note Generator saves time, ensures consistent formatting, reduces documentation burden, and helps maintain professional standards. It helps healthcare providers focus more on patient care while still maintaining thorough documentation. The tool is especially useful for busy practices looking to streamline their documentation process.
: Yes, you can use voice dictation to enter your notes. Simply click the microphone icon and speak your notes clearly. For example, you can dictate patient details like "25 year old male software engineer with increasing anxiety, lives with parents, no significant medical history, goals are reducing anxiety and improving sleep." The AI will then convert your spoken notes into a properly formatted SOAP note.