The Ultimate Guide to Veterinary SOAP Notes: From Template to AI [2025 Edition]

Intro: In the fast-paced world of a veterinary clinic, clear and efficient documentation is the cornerstone of exceptional patient care. The most common format for veterinary medical records is the SOAP note, which stands for Subjective, Objective, Assessment, Plan. Nearly every vet is trained to write SOAP notes, but not everyone does so consistently or effectively. This guide breaks down what a veterinary SOAP note is, why it’s essential, and how modern tools (like templates and AI scribes) are transforming this critical part of clinical workflow.

Every patient visit – whether a routine check-up or a complex emergency – generates a story. The SOAP structure provides a logical, universally understood way to organize that story. It ensures that any member of the team (or even an outside specialist) can quickly grasp the patient’s history, current status, and treatment plan from the record. In 2025, with the growing complexity of cases and increased use of pet insurance, well-structured SOAP notes are more important than ever for continuity of care and even for legal and financial reasons (insurers scrutinize records closely before reimbursing claims).

Let’s dive into the SOAP format, section by section, with examples and best practices.

What Are Veterinary SOAP Notes?

A SOAP note is a standardized method for recording medical information for each patient encounter. The acronym stands for:

• Subjective (S): The subjective observations – mainly the client’s observations and reason for visit.
• Objective (O): The objective findings – factual measurements and exam findings by the veterinary team.
• Assessment (A): The assessment or analysis – the vet’s medical conclusions or differential diagnoses.
• Plan (P): The plan – the next steps for treatment, diagnostics, and client instructions.

This structured format ensures that all key information is captured in an organized way. It separates what the owner reports from what the vet observes, and distinguishes those from the vet’s interpretation and the treatment plan. Not only does this help the originating vet, but it means any other vet who reads the record can follow the same clear train of thought.

The Four Sections of a SOAP Note (With Examples)

Understanding each component is key to effective documentation. Below, we define each section and provide an example of how it might be written in a veterinary context.

1. Subjective (S) – This is the “story” or historical information from the pet owner’s perspective. It includes the patient’s identifying info (species, breed, age, sex – often called signalment) and the chief complaint or reason for the visit, along with any observations the owner wants to report. Essentially, it’s all information that cannot be measured directly by the vet, but is described by the client.

• Definition: The owner’s observations and concerns, and relevant history leading up to the visit.
• Vet Example: Owner reports that Bella, a 4-year-old spayed Golden Retriever, has been shaking her head and scratching her right ear for 2 days. Appetite and energy are normal. No known pre-existing conditions; last ear infection was a year ago.

In this example, subjective data tells us why Bella is here (ear scratching) and some context (past issue, otherwise normal behavior).

2. Objective (O) – This section contains hard data and facts gathered during the exam and diagnostics. It includes physical exam findings, vital signs, diagnostic test results, and any other measurable observations. It’s essentially the evidence that the veterinary team collects.

• Definition: Quantifiable, observable findings from the examination and tests.
• Vet Example: Weight: 29.5 kg. T=101.8°F, P=110, R=24. Physical exam: All systems WNL except right ear. Right ear pinna is red; the canal has abundant dark brown malodorous debris. Pain on palpation of right ear canal; left ear is normal. Cytology of right ear discharge: 4+ Malassezia yeast and 3+ cocci bacteria observed.

Here, the objective section provides concrete details – vitals, exam findings (noting the right ear abnormalities), and a lab test result (cytology). Anyone reading this knows exactly what was found.

3. Assessment (A) – This is the analysis or diagnosis section. The vet synthesizes the subjective and objective information to arrive at a conclusion. It often contains the primary diagnosis if known, or a list of differential diagnoses (possible causes) if it’s not completely clear yet.

• Definition: The veterinarian’s medical assessment – typically a diagnosis or differential diagnoses list.
• Vet Example: 1. Otitis externa, right ear – likely yeast and bacterial infection secondary to underlying allergy. 2. Suspect atopy (allergic dermatitis) as predisposing factor given history of recurrent ear issues.

In this example, the vet’s assessment is that Bella has an outer ear infection and suspects an allergic component. They’ve numbered the problems (1 and 2) which is common if multiple issues or rule-outs are being noted.

4. Plan (P) – This section outlines what’s next – the treatment plan, further diagnostics, client communication, and follow-up recommendations. Essentially, it’s where the vet records what they are going to do (or did) for the patient and what they want the client to do.

• Definition: The course of action for this patient: treatments given or prescribed, tests ordered, client instructions, and plans for recheck or monitoring.
• Vet Example: 1. Discussed exam findings and diagnosis with owner. 2. Cleaned right ear with antiseptic solution. 3. Administered a long-acting ear medication (Osurnia) in the clinic. 4. Dispensed an oral antihistamine for 14 days for allergy management. 5. Provided an ear care handout and home instructions (emailed to client). 6. Recheck in 2 weeks for follow-up exam and cytology.

This plan example shows a comprehensive approach: client communication, in-clinic treatment, at-home meds, educational material, and scheduling a recheck.

Notice how the SOAP structure flows logically: S gives the why, O gives the what (findings), A gives the meaning (diagnosis), and P gives the next steps. A well-written SOAP note paints a complete picture of the visit.

Example Veterinary SOAP Note Template

To illustrate a full SOAP note, here’s an example template filled out for a common case – say a young cat with an upper respiratory infection. This demonstrates how the sections come together in a real scenario:

• Patient: "Simba," 8-month-old male neutered Domestic Shorthair cat.
• S (Subjective): Owner reports Simba started sneezing frequently 3 days ago. Now he has watery eyes and is less playful. Appetite slightly down, but he’s still drinking water. Simba is indoor-only, adopted from a shelter 2 months ago, and up to date on vaccines.
• O (Objective): T = 102.9°F, P = 160, R = 30. Bright, alert, responsive. Mild serous nasal discharge bilaterally. Moderate conjunctivitis (both eyes) with clear ocular discharge. No coughing, no labored breathing. Lungs clear on auscultation.
• A (Assessment): Feline Upper Respiratory Infection (URI) – most likely viral (e.g. feline herpesvirus) given the age, history, and symptoms. No evidence of pneumonia or severe bacterial infection at this time.
• P (Plan): 1) Supportive care – since this is likely viral, ensure hydration and nutrition. 2) Discussed signs to monitor with the owner (e.g. worsening lethargy, refusal to eat, colored nasal discharge). 3) Started L-lysine supplement to possibly help with herpesvirus. 4) Advised using a humidifier or bringing Simba into a steamy bathroom to ease congestion. 5) No antibiotics prescribed now (viral likely); instructed owner to call if any worsening or new symptoms. 6) No recheck needed unless not improving in 7–10 days.

This template shows a structured note that another vet could read and immediately understand the case and what was done. It’s thorough but concise – it captures the owner’s perspective, the clinical findings, the vet’s conclusions, and the treatment plan all in one standardized format.

Common Mistakes and Best Practices in Vet SOAP Notes

Even with a straightforward format, mistakes happen. Here are some common SOAP note pitfalls and how to avoid them:

Mistakes to Avoid:

• Mixing Subjective and Objective: Be careful not to put owner opinions or unverifiable statements in the Objective section. For example, writing "Patient seems in pain" in Objective is incorrect if that’s the owner’s perception. That belongs in Subjective. Objective should stick to facts like "yelps on palpation of abdomen".
• Being Vague: Avoid non-specific phrases like "Doing better." If you want to note improvement, quantify or qualify it. E.g., "coughing reduced from 10x/day to 2–3x/day" is more informative.
• Incomplete Plans: Forgetting to include follow-up instructions or monitoring guidance. Every problem noted in Assessment should have a corresponding plan item addressing it. If the plan doesn’t mention follow-up, that might be a miss (unless truly not needed).

Best Practices:

• Be Specific: Use precise language, measurements, and details. Rather than "a lot of discharge," say "approximately 5 mL of purulent discharge."
• Stay Objective in O: Only record what you see, hear, feel, smell or measure. Save interpretations for Assessment. For instance, note "limping on right hind leg" in O, and reserve "likely arthritis" for A.
• Support the Assessment: Ensure your A (diagnosis) is backed by the findings in S and O. If you diagnose otitis externa, the O section should have otoscopic or cytology findings to justify it.
• Close the Loop: For every diagnosis or problem in A, address it in P. If you list "dental disease" as a problem, your plan should include something like "dental cleaning or home dental care."
• Embrace Digital Tools: If you’re still hand-writing notes, consider switching to a digital format. Modern PIMS or even simple word processors can make notes more legible and templates easier to use. Handwritten notes run the risk of illegibility or being lost.

By avoiding common errors and following best practices, your SOAP notes will be more useful and professional. They’ll serve as strong medical, legal, and communication documents.

Why SOAP Notes Matter for Insurance and Legal Compliance

Beyond patient care, SOAP notes serve critical business and legal functions:

• Legal Protection: In any dispute or potential malpractice situation, the medical record is your primary defense. There’s a saying in medicine: “If it wasn’t written down, it didn’t happen.” Detailed SOAP notes show exactly what was observed, diagnosed, and advised. For example, if a client claims you never warned them about a pet’s condition, a note showing that conversation (e.g., "discussed poor prognosis with owner") is invaluable.
• Insurance Claims: Pet insurance is on the rise – as of 2023, about 5.7 million pets in the U.S. were insured, and the number is growing annually. Insurance companies often require medical records to process claims, especially for complex or expensive treatments. Incomplete or vague SOAP notes can lead an insurer to deny a claim, causing frustration for clients and extra work for your staff. For instance, if your note simply says "limb injury" without details, an insurer might delay reimbursement pending more info. Thorough documentation helps claims go through smoothly.
• Continuity of Care: If your patient is referred to a specialist or ends up in an emergency clinic after hours, your SOAP note is what the next veterinarian relies on. A clear record ensures they understand what you found and did, preventing duplicate work or dangerous delays. It also reflects well on your practice when you send complete, organized records – it shows professionalism and facilitates better care for the pet.
• Regulatory Compliance: While veterinary medicine isn’t federally regulated like human healthcare, many states have laws about veterinary record-keeping (e.g., requiring records be kept for X years, or that they contain certain info). Good SOAP notes help ensure you’re meeting any applicable standards. If your practice ever faces an audit or board complaint, having detailed notes that meet the expected format can make all the difference.

In short, SOAP notes are not just paperwork – they are legal documents and financial instruments as well. They protect you, support your clients’ insurance needs, and help other vets continue care appropriately.

How AI Scribes Are Changing Veterinary SOAP Notes

The biggest challenge with SOAP notes has always been the time they take. Writing a thorough note for each patient, especially when you have a full day of appointments, can significantly extend the workday. Enter AI scribes: tools that listen to the conversation during the exam and automatically generate a structured SOAP note draft. Here’s how AI can enhance each part of SOAP:

• Subjective: The AI scribe captures the owner’s narrative verbatim as needed. Important details like the pet’s diet, medications, or prior conditions mentioned by the owner are all recorded without the vet having to jot them down. This ensures nothing gets missed from the history.
• Objective: AI can integrate with devices and records – for example, if your scale and thermometer are connected, it can pull in weight and temperature. It can also transcribe the vet’s spoken exam findings. As the vet says "heart and lungs auscultate normally," the AI notes that in O. Some systems even know normal ranges and can flag abnormals.
• Assessment: While the AI won’t decide your diagnosis (that’s the vet’s job), by having all the S and O info documented, the vet can more quickly form the Assessment. In some cases, AI might suggest possible differentials if programmed to, but generally it provides a well-organized summary so the vet can add their assessment without having to recall everything from memory.
• Plan: AI can draft the plan as the vet discusses it. For example, if during the exam the vet says, "We’ll start Bella on ear drops and recheck in 2 weeks," the AI note will already have something like "Started medication XYZ; recheck appointment in 14 days" written out. Modern AI systems can even produce client discharge instructions in lay language based on the plan, and queue up reminders for follow-ups.

The result is that documentation time is cut dramatically – up to 80% less time, as mentioned earlier – and the notes often end up more detailed. Vets using AI scribe tools have found they rarely forget to include a detail, because the AI captured everything said during the exam. It also standardizes notes to the SOAP format, which can help maintain consistency across the practice.

Of course, an AI-generated note must be reviewed by the veterinarian. The vet needs to ensure the AI didn’t mishear something or include irrelevant info. But editing a draft is much faster than typing from scratch. Many vets liken it to having a very efficient assistant. One veterinarian quoted in AAHA’s Trends magazine noted that AI scribe technology “transcribes client conversations and incorporates the info into the record,” freeing vets of the tedium of typing and enabling focus on the patientlifelearn.comlifelearn.com. This technology is heralding “a new era of technological integration that touches every facet of veterinary practice”, not just documentation but overall workflowlifelearn.com.

How Pet Owners Can Request and Use SOAP Notes

A well-documented SOAP isn’t just useful to vets and insurers – it can be valuable to pet owners too. Pet owners have the right to request their pet’s medical records (in most jurisdictions, the clinic is the owner of the record, but clients are entitled to copies). Owners might want SOAP notes when:

• Moving or Changing Vets: If a client is relocating or switching to a new veterinarian, having copies of past SOAP notes ensures the new vet knows the pet’s history.
• Seeing a Specialist: If you refer a pet to a cardiologist or dermatologist, the owner can bring the relevant SOAP notes from your clinic so the specialist has the background.
• Emergency Situations: In an emergency visit, details from the last vet visit (e.g., recent lab results, medications given) can help the ER vet make fast, informed decisions.
• Insurance Claims: As discussed, owners may need to submit records to pet insurance for reimbursement. A complete SOAP note showing the diagnosis (Assessment) and treatments (Plan) can substantiate the claim.
• Personal Records: Some pet parents just like to keep a file on their pet’s health, or they want to understand the care provided. SOAP notes written in accessible language can help them follow the pet’s health narrative.

Typically, clinics will provide either a printout or a PDF of the record upon request. In 2025, many practices have client portals or online systems where owners can directly download visit summaries. It’s good practice for clinics to have a policy on record requests (e.g. requiring 24-48 hours notice to prepare records, and ensuring privacy measures like only releasing to the authorized owner). Educating clients that they can ask for records is also positive – it shows transparency. And when clients do have copies of SOAP notes, it often leads to better compliance (“Oh, the note says to recheck bloodwork in 6 months; I’ll make sure to schedule that”).

Frequently Asked Questions (FAQ)

Q: What exactly is a SOAP note in veterinary medicine?
A: It’s a standardized format for writing medical records for a patient visit. SOAP = Subjective, Objective, Assessment, Plan. Subjective is what the owner reports (symptoms, history). Objective is what the vet finds (exam and test results). Assessment is the diagnosis or analysis. Plan is the treatment and next steps. This format is widely taught and used because it forces a logical documentation of case details.

Q: Why are thorough SOAP notes so important?
A: They ensure high-quality patient care and safety by providing full information to anyone who reads the record. They also protect the clinic legally (documenting that proper advice and care were given). Furthermore, they’re increasingly needed for pet insurance; without a good note, an insurer might not reimburse a claim. Essentially, SOAP notes are the complete story of the pet’s medical visit – critical for continuity of care and proof of service.

Q: Can AI really write accurate veterinary SOAP notes?
A: Yes, with some oversight. Modern AI scribe systems have been trained on thousands of veterinary conversations and medical records. They can recognize medical terminology (drug names, anatomy, diagnoses) and even distinguish speakers (vet vs. client) to attribute subjective vs. objective info. They produce a draft that often captures details a busy vet might forget when later writing from memory. In many cases, vets find the AI-generated notes more detailed and just as accurate – after the vet’s review for any small corrections. Over time, as the AI learns a specific clinic’s style and common phrases, the accuracy gets even better. Still, the vet must review every note – the AI is a helper, not a licensed professional.

Q: What’s the main difference between the Subjective and Objective sections again?
A: Think of Subjective as the client’s words and subjective observations (e.g., "Max seems sad" or "I think he hurt his leg yesterday") – it’s everything the pet owner tells you or you infer from their perspective. In contrast, Objective is what you observe or measure (e.g., "Limping on right hind" or "X-ray shows a fracture"). If it’s not directly measurable or observed by the staff, it shouldn’t be in Objective. Sometimes it’s a fine line, but a good rule is: if it came from the client’s mouth, it’s Subjective; if you verified it or measured it, it’s Objective.

Conclusion: The Future of Veterinary Documentation

Thorough documentation via the SOAP format is non-negotiable in modern veterinary medicine – it underpins patient care quality, client communication, and legal/financial security. However, the traditional way of writing notes (scribbling on paper or typing long entries into the computer after a long day) is a major factor in vet burnout and lost productivity.

The good news is that technology is turning this pain point into an opportunity. AI scribes and smart templates represent the next evolution of veterinary record-keeping. By capturing the SOAP note through natural conversation, vets can maintain eye contact with clients and compassion for patients, rather than staring at a screen. The record gets created in the background, so to speak. Clinics that have adopted these tools are seeing benefits in accuracy, time savings, and even revenue (more thorough charges captured, more appointments fit into the day).

Ultimately, better documentation is a win for everyone: vets, clients, and patients. The vet team spends less time on charts and more on care (or gets well-deserved rest). Clients receive detailed visit summaries and feel confident nothing was overlooked. Pets benefit because their vets are less likely to miss important details or trends hidden in poorly organized records. As we move forward, expect AI-driven documentation to become as routine as digital x-rays – an accepted standard that makes veterinary practice more efficient and sustainable. By embracing these advancements while adhering to SOAP best practices, veterinary clinics in 2025 and beyond can ensure that every patient story is accurately told and efficiently captured, start to finish.

Related: The Veterinarians Complete Guide to SOAP Notes [2024], SOAP Template: Styles, Formats & Clinical Documentation, and SOAP Template: Consistent Clinical Documentation Guide.