What does a complete veterinary SOAP note look like?

A complete SOAP note has four parts: Subjective (history and owner-reported signs), Objective (exam findings and vitals), Assessment (diagnosis or differentials), and Plan (treatment, diagnostics, follow-up). A good note is specific, uses consistent structure, and reads clearly to any colleague who picks up the case.

Can I copy a SOAP note example and adapt it?

Yes — the examples below are written to be copied and adapted to your own cases. Change the signalment, findings, and plan to match your patient. Treat them as a starting scaffold, not a substitute for your own clinical judgement.

How long should a veterinary SOAP note be?

Long enough to be complete and defensible, short enough to write and read quickly. A routine wellness note might be a few lines per section; a complex workup needs more detail, especially in the objective and plan. Structure matters more than length.

What's the difference between a SOAP note and a template?

A template is the empty structure; a SOAP note is the filled-in record for a specific patient. Templates save you from starting blank, and an AI scribe can fill the template from your spoken consult — but the example below shows what the finished note actually reads like.

Veterinary SOAP Note Examples to Copy

Everyone learns the four letters of SOAP in school, but a blank framework and a finished note are different things. When you’re mid-shift, what actually helps is seeing a complete, well-written example you can copy and shape to your own case. So here are two — a routine canine wellness visit and a feline vomiting workup — with a note on what makes each section pull its weight. Copy them, change the details, make them yours.

What each section is doing

Quickly, so the examples make sense: Subjective is the story — history and what the owner reports. Objective is what you measured and observed — vitals and exam findings. Assessment is your read — a diagnosis or a ranked differential list. Plan is what happens next — treatment, diagnostics, client education, follow-up. For the full breakdown of the structure, see the SOAP notes guide.

Example 1 — Canine wellness visit

S: 3-year-old MN Labrador Retriever presented for annual wellness exam. Owner reports no concerns; eating, drinking, urinating, and defecating normally. Current on flea/tick prevention. Diet: commercial adult maintenance, ~2 cups BID. Normal activity, no coughing, vomiting, or diarrhoea.

O: BAR. Weight 32.4 kg (stable). T 38.6°C, HR 90 bpm, RR 20 brpm. MM pink and moist, CRT <2s. Eyes, ears, oral cavity WNL; mild tartar on caudal molars. Heart auscultation normal, no murmur. Lungs clear bilaterally. Abdomen soft, non-painful, no masses palpated. MSK: normal gait, full ROM. Skin/coat healthy.

A: Healthy adult dog. Early dental calculus (Grade 1).

P: DHPP and rabies boosters administered SQ. Recommended dental prophylaxis within 6–12 months and at-home brushing; provided handout. Continue current diet and prevention. Recheck in 12 months or sooner if concerns. Owner questions answered.

Example 2 — Feline vomiting

S: 8-year-old FS DSH presented for 2 days of intermittent vomiting (3–4 episodes/day, food and bile, no blood). Owner reports reduced appetite, normal water intake, no diarrhoea. Indoor-only, no known toxin or foreign-body access, no diet change. Last vaccinated 14 months ago.

O: QAR, mildly subdued. Weight 4.1 kg (down from 4.4 kg 6 months ago). T 38.9°C, HR 180 bpm, RR 28 brpm. MM slightly tacky, CRT ~2s — estimated 5% dehydration. Abdomen: mild discomfort on cranial palpation, no obvious mass or foreign body, no organomegaly. Remainder of exam WNL.

A: Acute vomiting, 8-year-old cat. Differentials: dietary indiscretion, pancreatitis, foreign body, early CKD, hyperthyroidism, IBD/neoplasia. Mild dehydration and modest weight loss noted.

P: Recommended CBC/chemistry, fT4, and abdominal ultrasound. Administered maropitant 1 mg/kg SQ and 30 mL/kg SQ fluids. Sent home on a bland diet for 48h with anti-emetic. Owner to monitor and return if vomiting persists >24h, worsens, or appetite doesn’t improve. Bloodwork results to be discussed on callback.

What makes these work

Notice a few things you can borrow: vitals sit in the objective with units, so they’re scannable; “WNL” is used for normal systems instead of typing each one out; the assessment on the feline case ranks a real differential rather than committing early; and every plan ends with a clear follow-up trigger. That’s what makes a note both fast to write and safe to hand off.

Letting the note write itself

Copying an example is a good scaffold, but you still fill it in by hand. This is where a structured AI scribe changes the workflow: you talk through the consult, and it drafts a note in exactly this shape — vitals in the objective, a formatted plan, a differential in the assessment — from your voice, ready to review. You get the finished note without typing it, and you can start from a proper template for structured cases like dental or lameness.

Coggo drafts complete SOAP notes like these from a recorded consult, for your review and sign-off. Try it free and see your next case written up in about 20 seconds.