1. Add the template
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Template content
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SOAP Note Subjective - Chief complaint and history of present illness (onset, duration, severity, associated symptoms, aggravating/alleviating factors). - Pertinent positives/negatives, focused review of systems, and patient goals for the visit. - Relevant past medical, surgical, medication, allergy, social, and family history as discussed. - Treatments tried and response; sick contacts or exposures when relevant. Objective - Vital signs, exam findings by system as performed, and pertinent negatives that affect medical decision-making. - Data reviewed today: labs, imaging, point-of-care tests, and outside records with brief interpretation. Assessment - Diagnoses / clinical impressions with brief reasoning. - Differential considerations and severity/risk stratification when relevant. Plan - Diagnostics, therapeutics, patient education, referrals, work/activity guidance, and follow-up timing. - Return precautions and shared decision-making noted when discussed.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Universal format clinicians already know how to review and sign.
- Works across primary care, urgent care, and many specialty follow-ups.
- Easy base for specialty variants (acute visits, chronic follow-ups, preventive care).
- Clear Subjective–Objective split keeps AI capture organized for quick attestation.
- 1Family and internal medicine visits
- 2Urgent care encounters
- 3Specialty follow-ups that still use SOAP
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Subjective 42-year-old presents with 3 days of productive cough, nasal congestion, and low-grade fever. Denies shortness of breath, chest pain, or hemoptysis. No sick contacts at home. Goals today: symptom relief and return-to-work guidance. Objective Temp 37.8°C, HR 88, BP 128/78, SpO2 98% on room air. HEENT: erythematous nasal mucosa, oropharynx mildly injected, no exudate. Lungs clear bilaterally. No cervical lymphadenopathy. Assessment Acute viral upper respiratory infection. Low suspicion for pneumonia or bacterial sinusitis at this time. Plan Supportive care: hydration, rest, OTC symptom relief as needed. Return precautions for dyspnea, persistent fever >3 days, or focal chest pain. Follow up PRN or if not improved in 7–10 days.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
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Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.