Veterinary SOAP notes: how to write them, with a free template

It's 7pm, the last consult finished an hour ago and you're still at a screen, writing up notes from memory. Across Europe, 64% of vets say their administrative workload has doubled, and clinical notes are a big part of that.

If you're a vet, a new graduate, or a practice manager trying to get consistent records out of a whole team, this guide covers the full job. I'll go through what belongs in each section and show you a complete worked example. I'll also cover what the RCVS expects, and give you a template you can put in front of every vet in your practice tomorrow.

A veterinary SOAP note is a clinical record with four sections: Subjective (the history and what the owner reports), Objective (what you find on examination), Assessment (your clinical interpretation and differentials), and Plan (diagnostics, treatment, client communication and follow-up).

The format comes from human medicine. Dr Lawrence Weed developed it in the 1960s as part of the problem-oriented medical record, and it stuck because it mirrors how clinicians think: gather the history, examine the patient, interpret, then act. Every veterinary school teaches it, and it remains the standard because a colleague picking up your case can find what they need in seconds.

What goes in each section

Subjective: the history

This is everything the owner tells you, plus your general impression of the patient before you lay hands on them. Record:

• The presenting complaint, in specific terms: how long, how often, when it started, whether it's getting better or worse.
• Relevant history: diet, appetite, drinking, toileting, current medications, vaccination status, previous episodes.
• What the owner has already tried at home.
• Relevant negatives from the history: no diarrhoea, no coughing, no known access to toxins.

The most common failure here is vagueness. "Owner reports dog unwell" tells the next vet nothing.

A bad example: Vomiting. Owner concerned.

A good example: Vomited 4 times since yesterday evening, last episode 6am. Scavenged a chicken carcass from the bin on Sunday. Refused breakfast today but drinking small amounts and keeping water down. No diarrhoea, no retching, bright at home between episodes.

The second version took 30 seconds longer to write and contains the timeline, a probable cause, and three relevant negatives. Six months from now, either version is all anyone will have.

Objective: what you found

Measurable findings only. No interpretation yet. Record:

• Vital signs: temperature, heart rate, respiratory rate, mucous membranes, CRT.
• Weight, and note the trend against the last visit. A drop of half a kilo means something in a cat and nothing in a Great Dane, but you can only judge it if it's written down.
• Body condition score.
• Systematic examination findings, in the same order every time.
• Relevant negatives from the exam: no palpable mass, no lymphadenopathy, no dehydration.

Pick one examination order and never vary it. Mine runs head to tail: eyes, ears, mouth, lymph nodes, heart, lungs, abdomen, musculoskeletal, skin. The order doesn't matter. Having one does, because it means you never skip a system on a busy afternoon, and your notes become predictable for anyone reading them.

Be precise. "Abdomen painful" records your conclusion. "Tenses and vocalises on deep cranial abdominal palpation, no discomfort caudally" records what happened, and it tells the next reader where to press.

Assessment: what you think is going on

This is your clinical reasoning, and it's the section most vets shortchange. A single word like "gastritis" records your conclusion but not your thinking. Write:

• Your most likely diagnosis, with the reasoning: which findings support it.
• Your differentials, and why they're less likely or can't yet be excluded.
• The patient's status if this is an ongoing case: improving, static, deteriorating.

The differentials are the part your future self will thank you for. If the patient comes back worse in 48 hours, a note that says "foreign body not excluded, no palpable abnormality today" means the second consult picks up where the first left off. It also shows any later reader that you considered it, which matters if the record is ever examined in a complaint.

Plan: what you're doing about it

Four things belong here:

• Diagnostics performed or scheduled, with results or expected dates.
• Treatment, written in full: drug, dose, route, frequency, duration. "Maropitant 28 mg SC once" can be checked and repeated. "Cerenia given" can't.
• Follow-up: when you want to see the patient again and what would bring that forward.
• Client communication: what you offered, what the owner chose, and the safety-netting advice you gave.

That last point deserves emphasis. If you offered radiographs and the owner elected conservative treatment first, record it. It's an honest account of a reasonable shared decision, and it protects both of you. A plan that only records what happened, without what was discussed, is half a plan.

A worked example

Poppy, 4-year-old female neutered Labrador, presented for vomiting.

S: Vomited 4 times since yesterday evening, last episode 6am. Scavenged a chicken carcass from the bin on Sunday per owner. Refused breakfast, drinking small amounts and keeping water down. No diarrhoea, no unproductive retching, no coughing. Bright at home between episodes. No current medications, vaccinations up to date, no previous GI history.

O: BAR. Wt 28.4 kg (28.9 kg in March). BCS 5/9. T 38.6°C, HR 96, RR 24, mm pink, CRT <2s. Skin tent normal. Mild tensing on deep cranial abdominal palpation, vocalises once. No palpable mass, no distension, no discomfort caudally. Peripheral lymph nodes unremarkable. Chest auscultates clearly.

A: Acute gastritis secondary to dietary indiscretion most likely, given scavenging history and mild exam findings. Differentials: pancreatitis (fatty meal, cranial abdominal discomfort; no pyrexia or severe pain today), GI foreign body (bone ingestion possible; not excluded on palpation, but keeping water down and no persistent vomiting). Metabolic causes unlikely in a bright, hydrated patient but not investigated today.

P: Discussed abdominal radiographs and cPL today versus symptomatic treatment with clear return advice; owner elected conservative management first. Maropitant 1 mg/kg (28 mg) SC given. Bland diet, small frequent meals for 48h, then transition back. Advised to return within 24h if vomiting continues, sooner if unproductive retching, abdominal distension, lethargy or continued anorexia. Recheck booked Thursday if not fully resolved. Estimate for imaging provided.

Notice what this note does. The timeline is complete. The weight trend is there. The differentials are recorded with reasoning, including the one that wasn't excluded. The declined diagnostics and the safety-netting advice are both in writing. If Poppy is rushed in obstructed on Thursday, this record shows a defensible decision made jointly with an informed owner. If a different vet sees her, they know exactly where the last consult left off.

What the RCVS expects

Clinical records are a professional obligation in the UK. The RCVS Code of Professional Conduct requires clear, accurate and adequately detailed records, and the supporting guidance is specific about what that means in practice:

• Records should be objective and factual, and entered at the time or as soon as reasonably practicable afterwards. The guidance also says to avoid recording assumptions or subjective comments about clients. Vent in the break room, never in the record.
• Records must provide a complete account sufficient to support continuity of care: examinations, treatments, test results, plans, who provided the care, and the advice given to the client.
• Corrections must preserve the original entry. You can amend a record to fix an error, but the amendment should be dated, show who made it, and sit alongside the original rather than replacing it. Deleting or overwriting an entry is how a simple mistake starts to look like something worse.
• On retention, the RCVS says records should be kept for as long as necessary given your legal and regulatory responsibilities. For food-producing animals, which in UK law includes horses, medicines records must be kept for at least 5 years under the Veterinary Medicines Regulations. Your professional indemnity policy may also set minimum retention periods, so check it before deleting anything.

None of this is onerous if the note was written properly in the first place. Every requirement on that list is met by the Poppy note above.

The free template

The template below gives every vet in your practice the same prompts. That's how you get consistent records across a team without writing a policy document nobody reads. Download it as an editable Word document and adapt the prompts to your caseload.

VETERINARY SOAP NOTE

Patient / Client / Date / Clinician:

S (Subjective)
Presenting complaint (duration, frequency, progression):
History (diet, appetite, drinking, toileting, medications, vaccination status):
Owner observations and home treatment:
Relevant negatives:

O (Objective)
Weight (vs last visit): · BCS: · T: · HR: · RR: · mm/CRT:
Systematic exam (same order every time):
Relevant negatives:

A (Assessment)
Most likely diagnosis and supporting findings:
Differentials and why less likely / not excluded:
Status (new / improving / static / deteriorating):

P (Plan)
Diagnostics (done or scheduled, with results):
Treatment (drug, dose, route, frequency, duration):
Client communication (options offered, decisions made, safety-netting advice):
Follow-up (recheck date, return-sooner criteria):

Writing them by voice

The habits above make a good note. They don't make it faster, and after a 12-hour day the temptation is always to cut the note short rather than the corners of anything else.

AI scribes now do the writing part of this job. The tool listens to the consult, transcribes it, and drafts the note directly into a SOAP structure for you to review and sign off. Whichever product you look at, test it the same way: run it on your own consults and read the draft against what was said in the room. Accuracy on your cases, your accents and your drug names is the only measure that counts.

Lupa Notes is the version built into our practice management system. It transcribes live from a phone or desktop and writes the note into whichever template you choose, SOAP included, or one your practice has built itself. Dr Michelle Mooridge at Burghley Vets saves around 3 minutes on every consult with it, which across a full day of appointments is most of an hour.

I think voice will be the normal way to write clinical notes within 18 months, and I'm glad about it. The structure of a good SOAP note stays the same. The typing is what changes hands, and every minute that moves from the keyboard back to the patient is a win for the animal, the client and the vet who gets home on time.

Put the template to work

Download the template, hand it to the team, and pick one habit from this guide to fix first. If you'd rather stop typing notes altogether, book a demo and we'll show you Lupa Notes on the kind of consults you actually see.