SOAP Note Template
The SOAP format (Subjective, Objective, Assessment, Plan) is the most widely used clinical note structure in UK general practice. Use this template as a reference or let WhiteFieldHealth generate it from a consultation recording.
WhiteFieldHealth
Built for reviewable clinical documentation, not generic AI output.
When to use a SOAP note
SOAP notes are ideal for GP consultations, outpatient follow-ups, and any encounter where you need a clear separation between patient-reported information, clinical findings, your assessment, and the agreed management plan. They are widely recognised by NHS trusts, CQC inspectors, and medical defence organisations.
Worked example: Hypertension follow-up
Subjective
48-year-old male presents for blood pressure review. Reports good compliance with amlodipine 5 mg OD for the past 6 weeks. No headaches, visual disturbances, or peripheral oedema. Denies chest pain, palpitations, or dyspnoea on exertion. Diet modification ongoing — reduced salt intake. Exercise: walking 30 minutes, 4 days per week. No relevant family history update. Non-smoker, alcohol 6 units/week.
Objective
BP 138/82 mmHg (previous 156/94 mmHg). HR 72 bpm, regular. BMI 27.3 (weight 84.2 kg, height 175 cm). No ankle oedema bilaterally. Heart sounds normal, no added sounds. Chest clear. Recent bloods (2 weeks ago): U&E normal, eGFR 88, fasting glucose 5.1 mmol/L, total cholesterol 4.8 mmol/L, HbA1c 38 mmol/mol.
Assessment
Essential hypertension, improving on current management. BP approaching target <140/90 mmHg per NICE NG136. QRISK3 score 11.2% — lifestyle modification alone insufficient, pharmacotherapy appropriate. No evidence of end-organ damage. Renal function preserved.
Plan
1. Continue amlodipine 5 mg OD — well tolerated, good response. 2. Reinforce lifestyle measures: dietary sodium <6 g/day, maintain exercise programme. 3. Repeat BP in 4 weeks — if sustained <140/90, continue current dose. If >140/90, consider up-titration to 10 mg. 4. Annual cardiovascular risk review due September. 5. Patient advised to monitor for ankle swelling and report promptly. 6. Safety-net: attend sooner if headache, visual changes, or chest pain.
What makes a good SOAP note
Keep Subjective focused
Document what the patient reports, not your interpretation. Use their language where clinically appropriate and note relevant negatives.
Quantify the Objective
Include specific values for vitals, scores, and investigation results. Trends matter — note previous readings for comparison.
Reference guidelines in Assessment
Cite NICE, BNF, or local guidelines where they inform your clinical reasoning. This supports audit and peer review.
Make the Plan actionable
Number each action item. Include drug names with doses, specific time frames for follow-up, and clear safety-netting advice.
Write contemporaneously
Complete your SOAP note as close to the consultation as possible. Delayed documentation increases the risk of missing key details.
How WhiteFieldHealth generates SOAP notes automatically
Record your GP consultation or upload an audio file, and WhiteFieldHealth transcribes the encounter, identifies clinical entities, and maps the content into the SOAP structure automatically. The draft is ready for review within seconds, not minutes. Drug mentions are cross-referenced against BNF and NICE guidance via our AI medical scribe pipeline, adding a layer of safety checking that manual documentation cannot match.
Designed for GP surgeries and outpatient clinics, the platform fits into your existing workflow without additional hardware. See pricing for plan details.
Generate SOAP notes automatically
Record consultations and get structured, reviewable SOAP notes in seconds. No manual template filling required.