Veterinary SOAP Note Examples and Templates

If you've read our guide to the SOAP format, the next thing that helps is seeing it in action. This article gives you a reusable template and two worked examples you can adapt for your own consultations.

(The examples below are illustrative, to show the structure — they are not clinical guidance.)

A reusable SOAP template

Copy this and fill in the four sections for every consultation:

S — Subjective: Chief complaint and history in the owner's words. Duration and progression, appetite, water intake, energy, behaviour, any home treatment, and relevant medical or vaccination history.

O — Objective: Measurable, observed findings. Temperature, pulse, respiration, weight, body condition score, and your physical-exam findings by system.

A — Assessment: Your clinical interpretation — a diagnosis where you have one, or a list of differentials.

P — Plan: Diagnostics, treatment, client communication, and follow-up. What happens next, and when.

Example 1 — Dog, vomiting

S: Owner reports Bella (5y FS Labrador) has been lethargic for three days, eating about half her usual amount. Vomited twice yesterday and once this morning. No diarrhoea. No known access to toxins. Vaccinations up to date. No previous medical issues; on no current medication.

O: BAR but quiet. T, P, R within normal limits. Mild dehydration estimated. Abdomen soft, mild discomfort on cranial palpation, no masses or foreign body palpable. Mucous membranes pink, CRT normal. Remainder of exam unremarkable.

A: Acute gastritis, most likely dietary. Differentials include foreign body, pancreatitis, and infectious causes.

P: Discussed conservative management vs further diagnostics with owner. Symptomatic treatment and a bland diet plan started; anti-emetic and fluid support as indicated. Owner advised on warning signs. Recheck in 48 hours or sooner if vomiting persists or worsens. Bloods/imaging discussed if no improvement.

Example 2 — Cat, itchy skin

S: Owner reports Milo (3y MN DSH) has been scratching and over-grooming for two weeks, worse around the neck and tail base. Indoor-outdoor. No new diet or products. One other cat in the home, not affected.

O: Patchy alopecia and excoriations over dorsal neck and tail base. Flea dirt present on coat brushing. No obvious ectoparasites otherwise. Ears clean. Remainder of exam unremarkable.

A: Flea allergy dermatitis most likely, given distribution and flea dirt. Differentials include other hypersensitivities and dermatophytosis.

P: Started appropriate flea control and discussed treating all in-contact animals and the environment. Symptomatic relief for pruritus as indicated. Owner advised on strict, ongoing flea prevention. Recheck in two to three weeks; further work-up if not resolving.

Make good notes the easy path

The reason records get rushed is friction. A consistent template removes the blank-page problem, and structured fields mean nothing important gets missed. To go a step further, an AI scribe can draft the SOAP note from your dictation while you talk — you review and save, rather than typing it up after every consult.

Good notes also keep you compliant. For what a record must contain and how long to keep it, see our guide to veterinary record-keeping requirements in South Africa. And to see how DigiVet structures every consultation around SOAP, take a look at the medical records features.