Template
SOAP note template
SOAP is four sections: Subjective (what the patient reports), Objective (what you measured or observed), Assessment (what you think it is), Plan (what happens next). When a note is drafted by an AI scribe, the section that goes wrong is almost always the boundary between S and O — a model hears "her ankle is swollen" and cannot always tell whether the patient said it or you saw it. Reviewing that boundary first catches most draft errors in a few seconds.
§The example above is illustrative and not a clinical guideline. This page is general information about documentation structure, not medical advice. Where an AI scribe drafts the note, the clinician remains responsible for its accuracy and for signing it. Scriben’s clinical console is in preview and not yet available to buy — the pages here rank other vendors, not us. The pen ships today at $129; join the healthcare preview for the rest.
Step by step
How it actually works.
01 / Keep S and O genuinely separate
Subjective is what you were told. Objective is what you found. This is the boundary an AI draft most often blurs, because the conversation does not signpost it — the patient says "my ankle is swollen" in the same minute you observe that it is. Read the two sections against each other first.
02 / Assessment is reasoning, not a label
A diagnosis alone does not document your thinking. "Grade II lateral ankle sprain, Ottawa rules negative so no imaging" tells the next clinician why you did not order an X-ray. A model will usually write the label and drop the reasoning unless the reasoning was said out loud.
03 / The Plan needs an owner and a trigger
Not "review in two weeks" but "review in 2 weeks or sooner if unable to weight-bear". The trigger is what makes the plan safe, and it is the part most often missing from a generated draft because it was implied rather than stated.
04 / Say the numbers out loud
An ambient scribe writes what it hears. Vitals read silently off a screen do not reach the note. Clinicians who get the most out of these tools narrate the objective findings during the examination — which is also good practice for the patient in front of you.
05 / Review the draft in section order
S against O, then A for reasoning, then P for owner and trigger. Four checks, under a minute, and it catches the great majority of what a draft gets wrong.
Copy this
The template.
- The structure
S: [reported symptoms, history, context] / O: [vitals, exam findings, results] / A: [assessment and reasoning] / P: [treatment, follow-up, who acts]- Subjective
S: 34F, 3 days of right ankle pain after inversion injury playing netball. No prior ankle injury. Weight-bearing with discomfort. No numbness.- Objective
O: Afebrile. Right lateral malleolus swelling and tenderness over ATFL. No bony tenderness at posterior malleolus. Able to bear weight 4 steps. Neurovascularly intact.- Assessment
A: Grade II lateral ankle sprain. Ottawa rules negative, so imaging not indicated today.- Plan
P: RICE, NSAIDs as needed, air-cast for 2 weeks. Physio referral sent. Review in 2 weeks or sooner if unable to weight-bear. Pt given written advice.
Questions
The ones people actually ask.
What does SOAP stand for?
What goes in Subjective versus Objective?
Can an AI scribe write a SOAP note?
Why does my AI-generated note miss the vitals?
Is there a free SOAP note template?
Where this comes from
We make a pen that does this.
Scriben is a real ballpoint that records the room to its own storage for up to 18 hours, with no phone and no network, then turns the conversation into a transcript, a summary and the work that follows. It is $129 once. This page would be worth reading whether or not you buy one — that is rather the point of it.