Veterinary SOAP Notes: Templates, Examples & AI Writing Tools

SOAP notes are the backbone of veterinary medical documentation. A well-written SOAP note protects you legally, ensures continuity of care, and communicates patient status clearly. But writing detailed SOAP notes takes time—time you could spend with patients.

This guide covers SOAP note structure, provides veterinary-specific templates, and explores how AI tools are transforming documentation in modern practices.

What is a SOAP Note?

SOAP is an acronym for the four sections of a structured medical note:

• S - Subjective: What the owner reports; patient history
• O - Objective: What you observe and measure; physical exam findings, vitals
• A - Assessment: Your diagnosis or differential diagnoses
• P - Plan: Treatment, medications, follow-up, client instructions

This format creates consistent, comprehensive documentation that any veterinary professional can quickly understand.

Why SOAP Notes Matter

Medical-Legal Protection

Thorough documentation is your best defense in case of complaints or litigation. If it wasn't documented, it didn't happen.

Continuity of Care

When another veterinarian sees your patient (emergency, referral, or you're on vacation), good SOAP notes let them pick up seamlessly.

Communication

SOAP format creates a shared language across your team—everyone knows where to find specific information.

Quality Improvement

Reviewing past SOAP notes helps identify patterns, evaluate treatment outcomes, and improve your clinical decisions.

SOAP Note Structure in Detail

S - Subjective

Record information from the pet owner and patient history:

• Chief complaint: Why is the pet here today?
• History of present illness: Duration, progression, associated symptoms
• Owner observations: Changes in behavior, appetite, elimination
• Current medications: What the pet is currently taking
• Allergies: Known drug or food reactions

O - Objective

Document your findings from physical examination and diagnostics:

• Vital signs: Temperature, heart rate, respiratory rate, weight
• General appearance: Mentation, body condition, hydration
• Systems examination: Findings organized by body system
• Diagnostic results: Lab work, imaging, other test results

A - Assessment

Document your clinical thinking:

• Primary diagnosis: Your most likely explanation
• Differential diagnoses: Other conditions to consider, ranked by likelihood
• Problem list: All active issues identified
• Clinical reasoning: Why you're thinking what you're thinking

P - Plan

Document your treatment plan clearly:

• Diagnostics ordered: Tests and imaging
• Treatments administered: In-clinic procedures
• Prescriptions: Medications with dosing
• Client instructions: Home care, diet, activity restrictions
• Follow-up: When to return, what to watch for
• Prognosis: Expected outcome

Veterinary SOAP Note Templates

Use these templates as starting points. Customize based on your practice preferences.

General Wellness Exam Template

S: Presenting for wellness exam. Owner reports [no concerns / concerns with...]
   Appetite: [normal/increased/decreased]
   Drinking: [normal/increased/decreased]
   Energy: [normal/increased/decreased]
   Elimination: [normal/abnormal - describe]
   Current medications: [list or none]
   Current diet: [brand/type, amount, frequency]

O: T: ___°F  HR: ___ bpm  RR: ___/min  Weight: ___ kg
   General: [mentation, BCS, hydration]
   EENT: [eyes, ears, nose, throat]
   Oral: [teeth, gums, tartar grade]
   CV: [rhythm, murmur Y/N, pulses]
   Resp: [lung sounds, effort]
   Abd: [palpation findings]
   LN: [palpable nodes]
   MS: [gait, joints]
   Integument: [skin, coat]
   Neuro: [if assessed]

A: [Age]-year-old [breed] [intact/neutered] [male/female]
   - Overall health status
   - Any issues identified

P: Vaccines: [list administered]
   Parasite prevention: [recommendations]
   Dental: [grade, recommendations]
   Recommendations: [list]
   Next visit: [timeframe]

Sick Patient Template

S: Presenting for [chief complaint]
   Duration: [how long]
   Progression: [getting better/worse/same]
   Frequency: [if applicable]
   Associated signs: [other symptoms observed]
   Changes in: appetite/drinking/urination/defecation/activity
   Current medications: [list]
   Allergies: [list or NKDA]
   Recent events: [boarding, diet change, toxin exposure, etc.]

O: T: ___°F  HR: ___ bpm  RR: ___/min  Weight: ___ kg
   General: [mentation, BCS, hydration status]
   [Focused exam findings based on complaint]

   Diagnostics:
   [Results or "pending"]

A: Problem list:
   1. [Primary problem] - [differential diagnoses]
   2. [Secondary problem if applicable]

P: Diagnostics: [ordered tests]
   Treatments administered: [list]
   Prescriptions:
   - [Drug, dose, frequency, duration]
   Client instructions: [home care]
   Monitoring: [what to watch for]
   Follow-up: [when, under what circumstances]
   Prognosis: [expected outcome]

How AI is Changing SOAP Note Documentation

Artificial intelligence is revolutionizing veterinary documentation in several ways:

Voice Dictation with Auto-Structuring

Modern AI dictation goes beyond simple speech-to-text:

• Speak naturally during your exam—no special commands or formatting
• AI recognizes context and sorts content into S, O, A, P sections
• Veterinary vocabulary accuracy (drug names, conditions, anatomical terms)
• Edit and approve rather than write from scratch

Time savings: Veterinarians using AI dictation report saving 30-45 minutes per day on documentation.

Template Auto-Population

AI can pull relevant information from patient history to pre-fill templates:

• Previous diagnoses and ongoing issues
• Current medications
• Last vital signs for comparison
• Vaccination status

Diagnostic Suggestions

Some AI systems analyze your Subjective and Objective findings to suggest:

• Differential diagnoses ranked by likelihood
• Recommended diagnostics based on presentation
• Standard treatment protocols

SOAP Note Best Practices

Be Specific

• ❌ "Abdomen normal"
• ✅ "Abdomen soft, non-painful on palpation, no masses or organomegaly appreciated"

Document Negatives

Recording what you didn't find is just as important as what you did:

• "No murmur auscultated"
• "No lameness observed"
• "No masses palpated"

Use Objective Language

• ❌ "Dog seemed uncomfortable"
• ✅ "Dog exhibited guarding behavior and vocalized on abdominal palpation"

Time-Stamp Important Events

For hospitalized patients or procedures, note when things happen:

• "10:45 - Vomited x1, small amount bile"
• "14:30 - Administered Cerenia 1mg/kg SQ"

Complete Every Section

Even if brief, every section should have content. Use "Not assessed" rather than leaving blank if a system wasn't examined.

Common SOAP Note Mistakes

1. Incomplete subjective: Missing duration, progression, or relevant history
2. Vague objective: "WNL" without specifying what was examined
3. Assessment without reasoning: Diagnosis listed but not supported by findings
4. Missing client instructions: Plan says "send home meds" without specific guidance
5. No follow-up plan: When should the patient return? What signs warrant emergency visit?
6. Delayed documentation: Writing notes hours later from memory increases errors

Efficient SOAP Note Workflow

Maximize documentation efficiency:

1. Pre-populate before entering room: Pull history, last vitals, ongoing problems
2. Document subjective during intake: Technician captures owner report
3. Use templates: Don't start from blank page every time
4. Dictate during exam: Voice-to-text while examining (with AI structuring)
5. Complete before leaving room: Don't let notes pile up
6. Review and sign immediately: Fresh memory catches errors

Frequently Asked Questions

How detailed should SOAP notes be?

Detailed enough that another veterinarian could understand the case and continue care. When in doubt, err on the side of more detail. Key findings, clinical reasoning, and patient instructions should always be thorough.

Can I use abbreviations?

Standard veterinary abbreviations (WNL, QAR, BCS, etc.) are acceptable. Avoid obscure or practice-specific abbreviations that others might not understand. When in doubt, write it out.

What if I need to correct a SOAP note later?

Never delete or overwrite original documentation. Add an addendum with the current date/time noting the correction and what is being changed. Most PIMS systems handle this automatically with audit trails.

How long should I keep SOAP notes?

Medical record retention requirements vary by state, but typically 5-7 years minimum. Many practices keep records indefinitely since digital storage is inexpensive.