Clinical Note Examples: SOAP, Progress, Telehealth, and Specialty Templates You Can Adapt

A clinical note is the signed record of a patient encounter: what the patient reported, what you found, what you concluded, and what happens next. Below are four complete clinical note examples you can adapt today: a SOAP note, a progress note, a telehealth note, and a behavioral health medication-management note.

The examples are deliberately full rather than skeletal. A four-line outline shows the shape of a note but not the level of detail that holds up when someone else reads the chart six months later.

Which clinical note format should you use?

Use SOAP for a new problem, a progress note for follow-up on a known one, and a telehealth note whenever the visit is remote. Behavioral health practices often use DAP or BIRP for therapy sessions. The format matters less than consistency: pick one per visit type and use it every time.

SOAP note example

SOAP, first described by Larry Weed, separates what the patient tells you from what you observe, then ties both to your reasoning (StatPearls, SOAP Notes).

• S: 47-year-old woman, 3 days of right lower quadrant pain that began periumbilical and migrated. Worse with movement. Nausea, one episode of vomiting. No diarrhea, urinary symptoms, or vaginal discharge. LMP 12 days ago. No prior abdominal surgery.
• O: T 100.4°F, BP 118/76, HR 96, SpO2 99% RA. Guarding, focal tenderness at McBurney's point with rebound, no rigidity. Urine hCG negative. WBC 13.8 with left shift.
• A: Acute appendicitis, likely. Migratory pain, focal rebound, low-grade fever, and leukocytosis together make it the leading diagnosis. Ovarian pathology and ureteral colic less likely but not excluded without imaging.
• P: NPO. CT abdomen/pelvis with contrast, STAT. Ondansetron 4 mg. Surgical consult placed and discussed by phone at 14:20. Patient told imaging may change the plan; agrees.

Progress note example

A progress note documents change since the last visit. Lead with the interval, not the whole history.

• Interval history: 58-year-old man, 8 weeks after starting lisinopril 10 mg for stage 1 hypertension. Home average 128/80 over 14 days. Lost 6 lb, walking 30 minutes five days a week. No cough, dizziness, or swelling.
• Current status: BP 130/82 in office. BMP: creatinine 0.9, potassium 4.3, both unchanged from baseline.
• Assessment: Hypertension, controlled on lisinopril 10 mg. Weight loss and activity are likely contributing. No adverse effects.
• Plan: Continue lisinopril 10 mg daily; adding medication now risks overshoot. Continue home log. Repeat BMP in 6 months. Follow up in 3 months, sooner if home readings exceed 140/90 consistently.

Telehealth note example

A telehealth note is a standard note plus the details that make a remote encounter defensible: modality, both locations, identity, consent, and what could not be examined. Payer rules on audio-only visits vary, so record the modality every time (HHS, telehealth billing).

• Encounter: Two-way video. Patient at home in Ohio, clinician in Ohio. Identity confirmed by date of birth and address. Verbal consent to telehealth obtained. 09:14 to 09:31.
• S: 34-year-old man, 4 days of sore throat, subjective fever, and fatigue. No cough. Denies difficulty breathing, drooling, or trouble opening his mouth.
• O: On camera: alert, full sentences, no respiratory distress. Home temperature 100.8°F. Tonsillar exudate visible. Patient reports tender anterior cervical nodes on self-palpation.
• Limitations: No auscultation, no direct palpation, no rapid strep available at this visit.
• A: Pharyngitis, Centor 3 by history and visualized exam. Peritonsillar abscess unlikely.
• P: Rapid strep and culture at the lab today; will prescribe based on result. Seek in-person or emergency care for trouble breathing or swallowing saliva, inability to open the mouth, or voice change. Patient repeated these back accurately.

Specialty example: behavioral health medication-management note

Behavioral health notes carry two things a primary care note often does not: a scored measure tracked over time and a documented risk assessment.

• Interval history: 29-year-old woman, 6 weeks on sertraline 50 mg for major depressive disorder. Sleeping 7 hours, back at work full time. Mild nausea in week one, resolved.
• Measures: PHQ-9 of 9 today, down from 17 at intake. GAD-7 of 6, down from 12.
• Mental status: Well groomed, euthymic, full range of affect, linear thought process. No perceptual disturbance.
• Risk: Denies suicidal ideation, intent, or plan. No access to firearms. Protective factors: partner, employment, engaged in weekly therapy.
• Assessment: Major depressive disorder, partial response. Residual low energy in the afternoons.
• Plan: Increase sertraline to 100 mg daily. Repeat PHQ-9 and GAD-7 in 4 weeks. Continue therapy. Crisis line and safety plan reviewed.

What makes a clinical note hold up in chart review?

A note holds up when another clinician can follow your reasoning from the assessment to the plan without asking you. In practice, that comes down to five habits:

• Reasoning, not just a diagnosis. The assessment should explain why the plan follows.
• Pertinent negatives. "No chest pain, no dyspnea" does more work than a page of normal findings.
• No unedited copy-forward. A carried-over exam that describes findings you did not check is the most common documentation problem.
• Plans with intervals. "Follow up as needed" does not close the loop.
• Return precautions. What you told the patient to watch for is often the most important line in the note.

How SigmaMD turns these examples into note templates

In SigmaMD, any of the formats above becomes a reusable note template in a few minutes. Practices build note templates and snippets in Practice Settings, insert them into a note by typing / and the shortcut, and pull chart data with $ variables such as $patientFullName and $patientAge, so the scaffolding never gets retyped (Efficient Clinical Documentation with Note Templates).

Templates can be nested. A telehealth encounter block, for example, can be its own template embedded in every visit type, so remote visits always carry the same consent and location lines (Nesting Templates). Typing {{!}} adds a note blocker: the note cannot be signed until that spot is filled, so the risk assessment in a behavioral health template cannot quietly ship empty.

SigmaMD Scribe writes the note into whichever template the practice builds. SigmaMD provides a default Scribe-enabled SOAP template, and a practice can turn any of its own templates into a Scribe-enabled one, with bracketed instructions telling Scribe what to capture in each section (Best Practices for Scribe-Enabled Templates). Scribe works in the exam room and on telehealth calls, and it can also draft a plain-language Recap for the patient alongside the clinical note. For one physician's experience, read Dr. Dhanji on AI Scribe and patient care.

Before the visit, Sigma AI, SigmaMD's in-app assistant, answers plain-language questions about the patient's chart, such as recent labs, medication changes, or vitals trends, and summarizes outside faxes and scans so the summary can be added straight to the note (Sigma AI Overview). That is the interval history in a progress note, gathered in seconds instead of clicks.

For behavioral health practices weighing their setup, what cash-pay behavioral health practices need from their software covers the rest of the workflow.

FAQ

What are the four parts of a SOAP note?

Subjective (what the patient reports), Objective (exam, vitals, and results), Assessment (your diagnosis and reasoning), and Plan (treatment, orders, education, and follow-up).

What is the difference between a SOAP note and a progress note?

A SOAP note documents a full encounter, often for a new problem. A progress note documents what changed since the last visit for a known problem, so it leads with the interval history.

What should a telehealth note include?

The modality, the patient's and clinician's locations, how identity was verified, consent, anyone else present, the standard note, and an explicit statement of what could not be examined remotely.

Can I use these clinical note examples in SigmaMD?

Yes. SigmaMD note templates and snippets are fully customizable, so each example can be built as a template, and SigmaMD Scribe will fill it during the visit.

Bring the note type you write most often to a SigmaMD demo and watch Scribe write it into your own template.