Family medicine SOAP note example and template for primary care
A family medicine SOAP note has four parts: Subjective (chief complaint, history of present illness, review of systems), Objective (vitals, exam, results), Assessment (a numbered problem list) and Plan (what you will do for each problem). Below are three complete fictional examples, an acute sore throat, a type 2 diabetes follow-up and acute low back pain, plus a copy-ready template for family physicians, nurse practitioners and physician assistants.
Want to see an AI-drafted Medical SOAP note first? Open a fictional sore-throat visit note in the MentalNote editor, no sign-up needed.
Facts checked on 23 October 2026. All patients on this page are fictional. This is documentation guidance, not clinical, coding or billing advice: follow current guidelines, your payer's rules and your own judgment.
Quick answer: what goes in each section
| Section | What goes in it | Common gap |
|---|---|---|
| S: Chief Complaint | The reason for the visit in one line. | Several complaints run together. List each one and give each its own HPI. |
| S: History of Present Illness | Onset, location, duration, character, severity, timing, aggravating and relieving factors, associated symptoms, pertinent negatives. Relevant history, medications with doses, allergies, social history. | Medications without doses, or no allergy status. |
| S: Review of Systems | The systems you actually asked about, by system. | Boilerplate "ROS otherwise negative" for systems not reviewed. |
| O: Objective | Vitals, exam by body system, results (point-of-care tests, labs, imaging, scores). | Normal exam text copied forward for systems not examined today. |
| A: Assessment | A numbered problem list: diagnosis or impression and status for each problem. | A diagnosis with no supporting findings in S or O. |
| P: Plan | Per problem: medications (name, dose, route, frequency, duration), tests, referrals, education, follow-up, return precautions. | No follow-up interval or return precautions. |
Since January 1, 2021, the level of an office or outpatient evaluation and management visit (CPT 99202-99205 and 99212-99215) is chosen by medical decision making or by total physician or other qualified health professional time on the date of the encounter. This rule does not apply to 99211. History and exam are documented as medically appropriate, so a focused, problem-based SOAP note is the norm in family medicine. If you bill by time, record the total time you personally spent on the date of the visit.
Example 1: acute visit for a sore throat
A same-day acute visit. The note shows a scored decision rule (the modified Centor, or McIsaac, score), a point-of-care test result, a prescription written in full and return precautions.
Fictional example: 24-year-old with a sore throat. A human-written, shortened illustration of a fictional visit (no real patient). It is not verbatim app output and not treatment guidance for a specific patient.
Chief Complaint
"My throat has been killing me for two days."
History of Present Illness
24-year-old woman with 2 days of sore throat, worse with swallowing, and fever to 101.5 F at home. No cough, no runny nose. Roommate had "strep" last week. Tolerating fluids. No drooling, no trouble breathing, no voice change. Took ibuprofen 400 mg this morning.
Medications: oral contraceptive daily. Allergies: no known drug allergies. Social history: nonsmoker.
Review of Systems
- Constitutional: fever and fatigue.
- ENT: sore throat; no ear pain, no nasal congestion.
- Respiratory: no cough, no shortness of breath.
- Skin: no rash.
Objective
Vitals: T 101.5 F (38.6 C), HR 96, BP 118/74, RR 16, SpO2 99% on room air.
Exam: Tonsils enlarged with bilateral white exudate; uvula midline; no trismus; no peritonsillar bulge. Tender anterior cervical lymph nodes bilaterally. Tympanic membranes normal. Lungs clear to auscultation. No rash.
Results: Rapid strep antigen test positive. Modified Centor (McIsaac) score 4: fever +1, absence of cough +1, tender anterior cervical nodes +1, tonsillar exudate +1, age 15 to 44 0.
Assessment
- Acute streptococcal pharyngitis (rapid antigen test positive). No signs of peritonsillar abscess or airway compromise.
Plan
- Amoxicillin 500 mg by mouth twice daily for 10 days. Ibuprofen or acetaminophen as needed for pain and fever, per package dosing. Fluids, rest.
Education: stay home from work until no fever and at least 12 hours of antibiotics. Finish the full course.
Follow-up: as needed if not improving in 48 to 72 hours.
Return precautions: trouble breathing, drooling or unable to swallow saliva, muffled voice, trouble opening the mouth, one-sided neck swelling, rash, or dark urine or joint pain in the weeks after.
Why it works: the HPI records the Centor items in the patient's own history (fever, no cough), the exam records the rest, and the result line shows how the score was reached. The pertinent negatives (no drooling, no trouble breathing, no voice change) document that the clinician looked for complications. This is the same kind of visit as the MentalNote sample note, which you can open and edit without signing up.
Example 2: chronic disease follow-up (type 2 diabetes)
A scheduled follow-up with more than one problem. The note shows a numbered assessment with status, a plan that matches each number, a medication started with its titration, and the standard diabetes care items (foot exam, kidney labs, eye exam).
Fictional example: 58-year-old with type 2 diabetes. A human-written, shortened illustration of a fictional visit (no real patient). It is not verbatim app output and not treatment guidance for a specific patient.
Chief Complaint
Diabetes follow-up.
History of Present Illness
58-year-old man with type 2 diabetes for 6 years, here for a 6-month follow-up. Takes metformin 1000 mg twice daily; misses about one dose a week. No low blood sugars. No increased thirst or urination. No numbness or tingling in the feet. Walks 20 minutes 3 days a week. Last dilated eye exam over 2 years ago. Hypertension on lisinopril 20 mg daily, no side effects. Atorvastatin 20 mg daily.
Allergies: no known drug allergies. Social history: never smoker, 2 to 3 drinks a week. Family history: no thyroid cancer; asked about medullary thyroid cancer and MEN 2 in the patient and family: none.
Review of Systems
- Constitutional: no weight loss.
- Eyes: no vision change.
- Cardiovascular: no chest pain, no leg swelling.
- Gastrointestinal: no abdominal pain; no history of pancreatitis.
- Neurological: no numbness or tingling.
Objective
Vitals: BP 128/78, HR 74, weight 98 kg (216 lb), BMI 33.1.
Exam: Feet: skin intact, no ulcers or calluses; 10-g monofilament sensation intact at all sites tested bilaterally; dorsalis pedis and posterior tibial pulses 2+ bilaterally.
Results: Point-of-care A1c today 8.4% (7.6% six months ago). Labs from July: eGFR 82, urine albumin-to-creatinine ratio 18 mg/g, LDL 92 mg/dL.
Assessment
- Type 2 diabetes without complications, not at goal (A1c 8.4%, individualized goal under 7%), rising over 6 months.
- Hypertension, at goal on lisinopril.
- Obesity, BMI 33.1.
- Hyperlipidemia, LDL 92 mg/dL on moderate-intensity statin; above the LDL goal of under 70 mg/dL given diabetes and additional cardiovascular risk factors.
Plan
- Continue metformin 1000 mg twice daily. Discussed options; shared decision to start semaglutide 0.25 mg subcutaneously once weekly for 4 weeks, then 0.5 mg once weekly. Counselled on nausea, eating smaller meals, and to stop and seek care for severe abdominal pain. Injection teaching done. Order basic metabolic panel and urine albumin-to-creatinine ratio before next visit; lipid monitoring as below. Referral to optometry for a dilated eye exam.
- Continue lisinopril 20 mg daily.
- Weight: discussed activity goal of 150 minutes a week; referral to diabetes self-management education.
- Discussed cardiovascular risk and the benefits and risks of higher-intensity statin therapy. Shared decision to increase atorvastatin to 40 mg by mouth daily. Repeat lipid panel in 8 weeks to assess response and adherence; LDL goal under 70 mg/dL.
Follow-up: 3 months with A1c; phone check in 4 weeks before the dose increase.
Return precautions: severe or persistent abdominal pain, persistent vomiting, or signs of dehydration.
Why it works: each problem has a status ("not at goal", "at goal"), the A1c trend shows why the plan changed, and the plan numbers match the assessment numbers. The history documents the screening questions that matter before starting the medication.
Example 3: acute low back pain
A common acute musculoskeletal visit. The note shows red-flag screening as pertinent negatives, a focused neurological exam, and why no imaging was ordered.
Fictional example: 42-year-old with low back pain. A human-written, shortened illustration of a fictional visit (no real patient). It is not verbatim app output and not treatment guidance for a specific patient.
Chief Complaint
Low back pain for 5 days.
History of Present Illness
42-year-old man with right-sided low back pain that started 5 days ago after moving furniture. Aching, 6/10, worse with bending and sitting, better lying down and with ibuprofen. Does not radiate below the buttock. No numbness, tingling or weakness in the legs. No bowel or bladder changes, no numbness in the groin or inner thighs. No fever, no weight loss, no history of cancer, no injection drug use, no steroid use, no fall or major trauma. First episode.
Medications: none daily. Allergies: no known drug allergies. No history of stomach ulcers, bleeding or kidney disease; not on blood thinners. Works in an office.
Review of Systems
- Constitutional: no fever, no weight loss.
- Genitourinary: no urinary retention or incontinence.
- Musculoskeletal: low back pain as above.
- Neurological: no leg numbness or weakness.
Objective
Vitals: BP 124/80, HR 72, T 98.2 F (36.8 C), pain 6/10.
Exam: Tenderness over the right lumbar paraspinal muscles; no midline spinal tenderness. Lumbar flexion limited by pain. Straight-leg raise negative bilaterally. Strength 5/5 in hip flexion, knee extension, ankle dorsiflexion and plantar flexion, and great toe extension bilaterally. Patellar and Achilles reflexes 2+ and symmetric. Light-touch sensation intact in both legs. Normal gait.
Results: Not documented.
Assessment
- Acute nonspecific low back pain, right lumbar strain likely. No red flags on history or exam; no signs of radiculopathy.
Plan
- No imaging at this time (under 6 weeks, no red flags). Stay active and avoid bed rest. Heat for 15 to 20 minutes several times a day. Ibuprofen 400 mg by mouth every 8 hours as needed with food, for up to 7 days. Home exercise handout given.
Follow-up: in 3 to 4 weeks if not improving; consider physical therapy referral then.
Return precautions: new leg weakness or numbness, numbness in the groin or inner thighs, loss of bladder or bowel control or trouble urinating, fever, or pain that is severe at night or steadily worsening.
Why it works: the red-flag screen is written as specific negatives, the neurological exam is complete enough to support "no radiculopathy", and the plan explains why imaging was not ordered. The Results line says "Not documented." rather than leaving a blank, which is how MentalNote marks a section the visit did not cover.
Family medicine SOAP note template
Copy this into your EHR or a document and delete the lines you do not need. Bracketed text is a prompt, not content.
CHIEF COMPLAINT [Reason for the visit in one line, in the patient's words where possible] HISTORY OF PRESENT ILLNESS [For each problem: onset, location, duration, character, severity, timing, aggravating and relieving factors, associated symptoms, pertinent positives and negatives] Relevant history: [past medical/surgical history that matters today] Medications: [name, dose, frequency; adherence] Allergies: [drug and reaction, or "No known drug allergies"] Social history: [tobacco, alcohol, other substances, work, as relevant] REVIEW OF SYSTEMS [Only the systems asked about, by system, positives and negatives] OBJECTIVE Vitals: [BP, HR, temp, RR, SpO2, weight/BMI, pain score as measured] Exam: [findings by body system, only systems examined] Results: [point-of-care tests, labs, imaging, scored measures, with dates] ASSESSMENT 1. [Diagnosis or impression], [status: new / stable / improving / not at goal] 2. [...] PLAN 1. [Problem 1: medications (name, dose, route, frequency, duration), tests, referrals, education] 2. [...] Follow-up: [interval] Return precautions: [what should prompt a call or urgent visit]
The general SOAP note template has a downloadable Word version, and the Medical SOAP note generator page lists what MentalNote writes in each section.
Tips for primary care SOAP notes
- One problem, one number. Use the same numbering in the assessment and the plan so each order and prescription is tied to a problem.
- Write status, not just the diagnosis. "Hypertension, at goal" or "type 2 diabetes, not at goal" tells the next reader what changed.
- Pertinent negatives are findings. "No fever, no weight loss, no bowel or bladder changes" shows what you ruled out. Write the ones that matter for this complaint.
- Do not copy forward an exam you did not do. Template text for systems not examined today makes the note inaccurate.
- Write medications in full. Name, dose, route, frequency and duration, plus what was started, changed or stopped.
- Always close with follow-up and return precautions. They show the patient knows when to come back.
- Date older results. Keep labs from earlier visits separate from today's point-of-care results.
SOAP note vs H&P vs progress note
| Note | When it is used | What it covers |
|---|---|---|
| H&P (history and physical) | Hospital admission, a new patient establishing care, or before surgery. | Complete: chief complaint, HPI, full past medical and surgical history, medications, allergies, family and social history, complete review of systems, complete exam, assessment and plan. |
| SOAP note | An office visit, an acute problem or a chronic disease follow-up. | Focused on the problems seen that day, in Subjective, Objective, Assessment, Plan order. |
| Progress note | Any follow-up entry in the record; in hospitals, daily notes. | Often written in SOAP format; the name describes when the note is written, not a different structure. |
MentalNote writes Medical SOAP notes. It does not have an H&P, discharge summary or consult note format. For a new-patient visit, a Medical SOAP draft records the past history, medications, allergies and social history that were discussed in the History of Present Illness section.
Draft family medicine SOAP notes with MentalNote
- Record the visit in your browser, in the room or on a telehealth call, with the patient's consent. Choose the Medical SOAP format and get a draft when the visit ends.
- It does not fill gaps. The app instructs the AI to write "Not documented." for anything the visit did not cover, and not to add a normal finding, a number, a diagnosis or a code you did not state. You review, edit and sign every note.
- Start free: 5 scribe sessions a month, no time limit, no credit card. Premium is $99 a month or $990 a year.
- MentalNote is HIPAA-compliant, with a BAA included on every plan, the free plan too. You accept it in the app before your first session.
- Try it first: open the fictional sore-throat sample note in the editor, no sign-up needed.
More for medical clinicians: AI scribe for primary care and family medicine, AI scribe for nurse practitioners, Medical SOAP note generator, and HIPAA rules for SOAP notes.
Family medicine SOAP notes: common questions
What is a SOAP note in family medicine?
A SOAP note is the standard visit note in primary care. Subjective records what the patient reports: the chief complaint, the history of present illness and the review of systems. Objective records what the clinician measures and finds: vitals, the exam and test results. Assessment is a numbered problem list with a diagnosis or impression for each problem. Plan says what will be done for each problem: medications, tests, referrals, education, follow-up and return precautions.
What goes in the subjective section of a primary care SOAP note?
The chief complaint in a line, then the history of present illness for each problem: onset, location, duration, character, severity, timing, what makes it better or worse, associated symptoms, and pertinent positives and negatives. Add the relevant past history, current medications with doses, allergies and social history. The review of systems lists only the systems you actually asked about.
What goes in the objective section?
Vitals, physical exam findings by body system, and results such as point-of-care tests, labs, imaging and scored measures. Record only what was measured or examined at this visit, or label older results with their date. Avoid template text such as "lungs clear" for a system you did not examine.
How do I write the assessment and plan when the visit covers several problems?
Number the problems in the assessment and give each its own diagnosis or impression and status, such as new, stable, improving or not at goal. Then give each problem its own plan, using the same numbers. This keeps medications, orders and follow-up tied to the problem they treat, and it supports medical decision making if you choose the visit level by MDM.
What is the difference between a SOAP note and an H&P?
An H&P (history and physical) is the complete record taken when a patient is admitted or first establishes care: full past medical, surgical, family and social history, a complete review of systems and a complete exam. A SOAP note is the focused note for a single visit or a follow-up. It covers what is relevant to the problems seen that day. MentalNote writes Medical SOAP notes; it does not have an H&P format.
Should a SOAP note include ICD-10 codes?
The assessment should state the diagnosis in words. Many clinicians also add the ICD-10-CM code in the assessment or on the claim, following their EHR and billing workflow. MentalNote does not add a diagnosis or a diagnostic or billing code that you did not state in the visit; you add codes yourself.
Can AI write a family medicine SOAP note?
Yes, as a draft for you to review. MentalNote records the visit in your browser with the patient's consent and drafts a Medical SOAP note when the visit ends. It is instructed to write "Not documented." for anything the visit did not cover and not to add normal findings, numbers, diagnoses or codes you did not state. You check, edit and sign the note.
Are the SOAP note examples on this page real patients?
No. All three examples are fictional and written by people to show structure. They are not real patients, not verbatim app output and not treatment guidance for a specific patient.
Record the visit. Review the SOAP draft.
Open a fictional sore-throat visit and edit a prepared Medical SOAP note. When you're ready, sign up free: 5 web-app scribe sessions a month, no credit card. Premium is $99/month or $990/year.
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