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SOAP note template

Australian documentation guide

A four-section consult note for clinicians who want to separate what the person reports, what was observed, the clinician's assessment and the agreed plan. Copy the blank scaffold, then document the encounter in your own words.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Subjective

Establish the person’s main concern, when it began, how it has changed and what they hope to address. Distinguish their account from information supplied by a carer, records or another clinician.

Useful wording includes “reports”, “describes”, “denies” and “not asked”. A negative finding means the question was asked and answered; silence is not a denial. Preserve a meaningful quotation rather than substituting a diagnostic label.

Objective

Record observations, examination findings and measurements actually obtained, with units and the relevant side or site. Identify a remote encounter, declined examination or other limitation.

“Observed”, “measured”, “tender”, “non-tender”, “intact” and “not examined” describe different evidence. Avoid a blanket “normal examination” when only one finding was checked.

Assessment

Record the clinician’s stated interpretation, including uncertainty and alternatives only when they were expressed. Attribute an existing diagnosis to its source when it was not established at this visit.

“Confirmed”, “working impression”, “possible”, “under investigation” and “cause not established” have different meanings. Do not promote a reported symptom or pending test into a diagnosis.

Plan

Record what was discussed or agreed, who will act and any stated timing. Separate an action already completed from a proposed investigation, prescription or referral. Include the person’s preference or decision when it affected the agreed plan.

Use “ordered”, “offered”, “declined”, “agreed” or “awaiting” only when that status is established. This heading does not supply treatment or follow-up that was absent from the encounter.

Common omissions

The source of the history, the limits of an examination and the owner of a follow-up action are easy to lose. A copied heading does not prove that a question, assessment or action occurred.

Review before saving

Check that subjective reports remain distinct from observed findings, that the assessment preserves the clinician’s uncertainty, and that every plan action has its actual status. Keep author, encounter date and patient identity in the record system. Use professional guidance and local policy for assessment and care.

Worked examples

A minor forearm bruise

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

SUBJECTIVE: Person reports bumping their left forearm against a door yesterday. Local tenderness is improving. No numbness or loss of hand function reported.
OBJECTIVE: A 4 x 2 cm bruise is visible on the left forearm. Skin is intact. The clinician documents full active wrist movement and normal light-touch sensation in the hand.
ASSESSMENT: The clinician records a soft-tissue contusion of the left forearm.
PLAN: The clinician and person agree to monitor the area. The person will contact the practice if new concerns arise. No medicine was prescribed at this visit.

An administrative transfer-of-care discussion

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

SUBJECTIVE: Person is moving suburb and requests transfer of their existing records. No new clinical concern raised.
OBJECTIVE: No physical examination performed at this administrative visit.
ASSESSMENT: Transfer of care requested.
PLAN: Person consents to sending the existing summary to their nominated practice. Practice details will be confirmed before sending.

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.