Clinical Note Examples: SOAP, DAP, BIRP, and Progress Note Templates

Below are five clinical note formats, each with a blank template you can copy and a fully worked example underneath. Skip to whichever one you need — SOAP, progress, DAP, BIRP, or telehealth.

The examples are deliberately complete rather than skeletal. A four-line outline shows you the shape of a note but not the level of detail that actually holds up in a chart review.

What separates a good clinical note from a defensible one

Most documentation guidance stops at "be clear and accurate." The practical bar is higher:

• Your assessment explains your plan. If a reviewer cannot trace why you ordered what you ordered, the note is incomplete no matter how long it is.
• Pertinent negatives are recorded. "No chest pain, no dyspnea" is doing more work than three paragraphs of normal findings.
• Subjective and objective stay separated. The moment a patient's report gets written as fact, the note becomes harder to defend.
• It is written the same day. Detail decays fast, and late entries invite questions about accuracy.
• Uncertainty is stated as uncertainty. "Suspected" and "cannot exclude" are stronger documentation than false confidence.

1. SOAP note template and example

SOAP is the default for most encounters — subjective, objective, assessment, plan.

Blank SOAP template

• S: Chief complaint. History of present illness — onset, duration, character, aggravating and relieving factors. Relevant review of systems. Pertinent negatives.
• O: Vitals. Physical exam by system. Labs, imaging, in-office testing.
• A: Diagnosis or differential, with reasoning. Comorbidities affecting the plan.
• P: Medications with dose and duration. Orders. Patient education. Return precautions. Follow-up interval.

Worked SOAP example

S: 47-year-old woman with a 3-day history of sharp right lower quadrant pain. Began periumbilical and migrated. Worse with movement, better lying still. Nausea, one episode of vomiting yesterday. No diarrhea, no urinary symptoms, no vaginal discharge. LMP 12 days ago. No prior abdominal surgery.

O: Temp 100.4°F, BP 118/76, HR 96, RR 16, SpO2 99% RA. Alert, uncomfortable, guarding. Abdomen soft, focal tenderness at McBurney's point with rebound. No rigidity. Negative Murphy's. Bowel sounds present. Urine hCG negative. WBC 13.8 with left shift.

A: Acute appendicitis, likely. Migration of pain, focal RLQ tenderness with rebound, low-grade fever, and leukocytosis together make this the leading diagnosis. Ovarian pathology and ureteral colic are less likely given a negative hCG, no flank pain, and clean urinalysis, but neither is excluded without imaging.

P: NPO. IV access, LR 500 mL bolus. CT abdomen/pelvis with contrast, ordered STAT. Ondansetron 4 mg IV. Surgical consult placed, spoke with Dr. Alvarez at 14:20. Discussed likely appendectomy and that imaging may change the plan. Patient verbalized understanding. Return precautions reviewed with spouse.

2. Progress note template and example

Used for interval visits on an established problem, where the question is direction of travel rather than diagnosis.

Blank progress note template

• Interval history since last visit.
• Adherence and side effects.
• Objective data trend versus prior.
• Assessment of whether the problem is controlled, improving, or worsening.
• Plan changes with rationale.
• Next follow-up.

Worked progress note example

Interval history: Seen 8 weeks ago for newly diagnosed hypertension, started lisinopril 10 mg daily. Reports good adherence, no missed doses. Denies cough, dizziness, or swelling. Has been walking 25 minutes most days and cut back on takeout. No headaches or visual changes.

Objective: BP 128/78 today, 132/80 on recheck. Home readings averaging 130/79 over the last two weeks, log reviewed. Weight 189 lb, down from 196 lb. BMP today: creatinine 0.9 (was 0.9), potassium 4.2.

Assessment: Hypertension, improving and now near goal on lisinopril 10 mg. Renal function and potassium stable on ACE inhibitor. Weight loss and activity change are likely contributing. No adverse effects to date.

Plan: Continue lisinopril 10 mg daily, no dose change — home average is at target and adding medication now risks overshoot. Continue home BP log. Repeat BMP in 6 months. Follow up in 3 months, sooner if home readings exceed 140/90 consistently.

3. DAP note template and example

DAP — data, assessment, plan — collapses subjective and objective into one section. Common in behavioral health and case management, where the distinction matters less than the narrative.

Blank DAP template

• D: What the patient reported and what you observed, together. Direct quotes where they matter.
• A: Your clinical interpretation. Progress toward treatment goals. Risk assessment.
• P: Interventions, homework, referrals, next session.

Worked DAP example

D: Patient arrived on time, casually dressed, good eye contact. Reports a chronic nighttime cough for 6 weeks, worse when lying flat, occasionally waking him. History of asthma diagnosed in childhood, has not used a controller in years. Uses albuterol "maybe four times a week." Describes a new cat in the home since October. Lungs with scattered expiratory wheeze bilaterally, no crackles. Peak flow 380, personal best 520.

A: Poorly controlled asthma, likely with a new environmental trigger. Albuterol use four times weekly and nocturnal symptoms both exceed the threshold for intermittent disease. Peak flow at 73% of personal best supports active obstruction rather than post-viral cough.

P: Start fluticasone 110 mcg, two puffs twice daily, with spacer. Technique demonstrated and teach-back confirmed. Continue albuterol as rescue only. Discussed keeping the cat out of the bedroom and washing bedding weekly. Asthma action plan provided in writing. Follow up in 3 weeks with repeat peak flow.

4. BIRP note template and example

BIRP — behavior, intervention, response, plan — is built for therapy sessions, where what you did and how the patient responded is the substance of the encounter.

Blank BIRP template

• B: Observed presentation and reported experience. Mental status where relevant.
• I: What you did this session — the specific modality or technique, not just "supportive therapy."
• R: How the patient responded, in session.
• P: Homework, frequency, referrals, risk plan.

Worked BIRP example

B: Patient presented anxious, speech rapid, difficulty staying on topic. Reports 3 weeks of initial insomnia averaging 4-5 hours of sleep, tied to a reorganization at work and an unclear reporting line. Describes anticipatory dread on Sunday evenings. Denies suicidal ideation, denies substance use as coping. Appetite intact.

I: Psychoeducation on the physiology of the stress response and its effect on sleep onset. Introduced cognitive restructuring, working through the specific thought "if I am reassigned everyone will know I failed" using evidence-for and evidence-against. Practiced paced breathing in session.

R: Patient engaged readily. Identified two pieces of counter-evidence without prompting and noted the thought "sounds harsher out loud than in my head." Visible reduction in psychomotor agitation after breathing exercise. Rated anxiety 7/10 at start, 4/10 at close.

P: Thought record, three entries before next session. Continue weekly for 4 weeks then reassess. Sleep hygiene handout provided. If insomnia persists past 4 weeks despite CBT-I basics, consider psychiatric referral for medication evaluation. No safety concerns at this time.

5. Telehealth visit note template and example

A telehealth note is a standard note plus the elements that make a remote encounter defensible: modality, location, consent, identity verification, and what could not be examined.

Blank telehealth template

• Modality (video or audio-only) and platform.
• Patient location and clinician location.
• Identity verified how.
• Consent to telehealth obtained.
• Others present.
• Standard S/O/A/P.
• Explicit limitations of remote exam.
• Escalation plan if condition worsens.

Worked telehealth example

Encounter details: Two-way video visit. Patient at home in Ohio, clinician in Ohio. Identity confirmed by DOB and address. Verbal consent to telehealth obtained and documented. Patient alone, no interpreter needed. Start 09:14, end 09:31.

S: 34-year-old man, 4 days of sore throat, subjective fever, and fatigue. No cough. Denies difficulty breathing, drooling, trismus, or neck stiffness. No known sick contacts. No rash.

O: On camera: alert, speaking in full sentences, no respiratory distress, no stridor. Self-reported home temp 100.8°F this morning. Posterior pharynx visible on camera with erythema and bilateral tonsillar exudate. Patient palpated own neck and reported tender anterior cervical nodes. Limitations: no direct palpation, no auscultation, no rapid strep or culture obtainable at this visit.

A: Pharyngitis, Centor 3 by history and visualized exam. Bacterial cause plausible but not confirmable remotely. Peritonsillar abscess unlikely given absent trismus, drooling, and voice change.

P: Rapid strep and culture at the lab today, order placed. Symptomatic care reviewed — fluids, acetaminophen, salt water gargles. Will prescribe based on result, expected within 24 hours. Explicit escalation: seek in-person or emergency care for difficulty breathing or swallowing saliva, inability to open mouth, or voice change. Patient repeated escalation criteria back accurately.

Five mistakes that show up in chart review

• Copy-forward without editing. A carried-over exam that describes findings you did not check is the single most common documentation problem.
• An assessment that only names a diagnosis. Without reasoning, the note cannot support the plan.
• Plans without intervals. "Follow up as needed" is not a plan and does not close the loop.
• Ambiguous abbreviations. Note the ones your own practice has agreed on and avoid the rest.
• No documented return precautions. What you told the patient to watch for is often the most important line in the note.

Writing these faster in SigmaMD

The formats above are the easy part. The friction is retyping the same scaffolding dozens of times a week.

In SigmaMD, the / shortcut inserts a macro — a saved snippet you or a colleague has built, which is where these templates live once you have set them up. The $ shortcut pulls structured data straight from the chart, so $patientFullName and $patientAge fill themselves in rather than being retyped.

Note blockers close the gap templates usually leave. Typing {{!}} anywhere in a macro marks a spot that must be filled before the note can be signed — the vitals line in a hypertension template, the exam limitations in a telehealth note. The note will not sign until the blocker is resolved, so the incomplete section cannot quietly ship.

Notes auto-save as you write, and changes made after signing are logged.

If you are evaluating documentation tools for a direct care practice, the question worth asking is not whether the editor is pleasant. It is whether the system makes your own best template the path of least resistance on a busy afternoon.