A veterinary SOAP note records a visit in four sections — Subjective (what the owner reports and how the patient presents), Objective (what you measure: TPR, exam findings, diagnostics), Assessment (what you think is going on, with differentials), and Plan (what you'll do: diagnostics, treatment, client communication, follow-up). Below are eight complete, copy-ready examples for the most common visit types: wellness exam, vaccination visit, dental procedure, lameness, vomiting and diarrhea, post-op recheck, euthanasia, and emergency triage. Copy the one you need, swap in your patient's details, and trim to what your case actually requires.
All examples use fictional patients and deliberately leave out specific medication names and doses — your treatment entries come from your own clinical judgment and your practice's protocols. The structure is the part worth stealing. (New to the format, or training someone who is? Start with our companion guide on how to write veterinary SOAP notes — what belongs in each section and why.)
Why these examples look the way they do
The SOAP format wasn't invented for veterinary medicine. It comes from Dr. Lawrence Weed's problem-oriented medical record, introduced to human medicine in his 1968 New England Journal of Medicine paper "Medical Records That Guide and Teach." Weed's argument was simple: a record organized around problems, with the clinician's reasoning visible at every step, is a record that another clinician can pick up cold and act on safely.
That's still the standard veterinary schools teach today. Washington State University's veterinary program puts it plainly in its documentation guide: your medical record "should stand on its own, providing a comprehensive review of the case," your "thought processes at each step should be evident to anyone reviewing the record," and it "serves as a legal record of diagnoses considered, treatment given, communications with clients, and your reasoning for any action (or lack of action)."
The same guide makes another point that matters for how you use the templates below: there is no one right way to write a SOAP. Different clinics, services, and clinicians have different expectations. What doesn't change is the job the note has to do — capture the owner's story, your findings, your reasoning, and your plan, in a way a colleague (or a licensing board) can follow.
One practical note before the examples: the AVMA recommends investing a few minutes to build record templates in your own voice, because "editing something written in your own voice is almost always faster than editing a generic version — or starting from scratch for each record." Treat everything below as raw material for exactly that.
1. Wellness exam
The annual wellness visit is the note you write most often, which makes it the best one to template. The trap is writing so little that the record is useless next year ("ADR, looks fine") or so much that you burn ten minutes documenting a healthy dog.
Patient: "Bella" — 6 y FS Labrador Retriever, 29.4 kg
Visit type: Annual wellness examination
S: Presented for annual wellness exam. Owner reports no concerns. Eating,
drinking, urination, defecation all normal. Activity level normal for age.
Diet: adult maintenance dry food, 2 meals/day, occasional treats.
Current on parasite prevention per owner. No coughing, sneezing, vomiting,
diarrhea, or changes in behavior noted at home.
O: BAR, well hydrated. BCS 6/9 (target 5/9). T 38.4°C, HR 88, RR 20.
EENT: mild dental tartar on maxillary premolars, gingiva pink, no oral
masses. Eyes and ears clean, no discharge. PLN: all peripheral lymph
nodes normal size. CV: no murmur or arrhythmia, pulses strong and
synchronous. Resp: clear on auscultation bilaterally. Abd: soft,
non-painful, no organomegaly palpated. Integument: coat good quality,
no masses noted. MSK: ambulatory x4, no pain on manipulation.
A: 1. Healthy adult dog — no significant abnormalities on exam.
2. Overweight (BCS 6/9) — early, diet-responsive.
3. Mild dental tartar — grade 1 periodontal disease.
P: 1. Discussed weight management: reduce daily ration ~10%, cut treats to
training-size only, recheck weight in 8 weeks (tech appointment, no
charge). Owner agreeable.
2. Discussed dental care options: daily brushing demonstrated; recommend
COHAT within 12 months if tartar progresses.
3. Vaccinations updated per practice protocol (see vaccination record).
4. Fecal sample submitted; owner to be called with results.
5. Continue current parasite prevention. Recheck in 12 months or sooner
if concerns.
What makes it work: every abnormality found in O appears in A (weight, tartar), and every line of A gets an action in P — including the conversation with the owner and their response. The WSU guide calls this out specifically: plans for client communication belong in the record, with "detail sufficient for effective communication with the medical team AND for legal purposes."
2. Vaccination visit
Shorter than a wellness exam, but it still needs a real exam section — you examined the patient before vaccinating, so document that you did.
Patient: "Milo" — 5 mo M Domestic Shorthair, 2.6 kg
Visit type: Kitten vaccination series, booster
S: Presented for scheduled kitten booster. Owner reports normal appetite
and energy, no vomiting/diarrhea, no sneezing. Litter box habits normal.
Indoor-only. No reaction noted after previous vaccine visit.
O: BAR, playful. T 38.6°C, HR 200, RR 32. Hydration adequate. Mucous
membranes pink, CRT <2s. Heart and lungs auscult normally. Abdomen soft.
No nasal or ocular discharge. Body weight up 0.4 kg from last visit —
appropriate growth curve.
A: Healthy kitten, appropriate for scheduled booster.
P: 1. Booster administered per practice protocol; site and product recorded
in vaccination log.
2. Owner advised on normal post-vaccine observations and when to call
(lethargy >24h, facial swelling, vomiting, injection-site swelling).
3. Final kitten visit scheduled in 3–4 weeks; discussed timing of
neutering at that visit.
What makes it work: the pre-vaccination exam is documented, the client education is documented, and the note points to the vaccination log rather than duplicating it. If the product, batch, and site live in your practice management system's vaccine module, reference it — don't write it twice.
3. Dental procedure (COHAT)
Procedure notes need more Objective detail than outpatient visits, because the record has to reconstruct what was found and what was done under anesthesia — the owner wasn't there, and next year's clinician wasn't either.
Patient: "Herman" — 8 y MN Dachshund, 7.1 kg
Visit type: Comprehensive oral health assessment and treatment (COHAT)
S: Admitted for scheduled COHAT following grade 2–3 dental tartar and
halitosis noted at wellness exam. Owner reports patient eating normally
but "chewing on one side." No other concerns. Fasted as instructed.
O: Pre-anesthetic exam: BAR, T 38.3°C, HR 110, RR 24, no murmur, lungs
clear. Pre-anesthetic bloodwork (in-house CBC/chem): unremarkable, values
within reference ranges.
Anesthesia: induced and maintained per practice protocol; monitoring
record attached (see anesthesia sheet).
Oral exam under GA: generalized moderate tartar and gingivitis. Full-mouth
dental radiographs obtained. Findings charted on dental chart (attached):
- 108: fractured crown with pulp exposure, periapical lucency on rads
- 309, 409: grade 2 furcation exposure, >50% attachment loss on rads
- Remaining dentition: gingivitis, no mobility, no pockets >3 mm
A: 1. Fractured 108 with pulp exposure and periapical pathology — extraction
indicated.
2. Periodontal disease 309/409 with significant attachment loss —
extraction indicated.
3. Generalized grade 2 periodontal disease, remainder of dentition
treatable with scale and polish.
P: 1. Owner called mid-procedure with radiographic findings and estimate
update; verbal consent received for extractions (time and staff
initials noted in comm log).
2. Surgical extraction 108, 309, 409 with regional local block per
protocol; gingival flaps closed with absorbable suture. Extraction
sites radiographed — no retained roots.
3. Full-mouth scale and polish completed.
4. Recovery uneventful; discharged same day with written post-dental
instructions: soft food 7 days, no chew toys 14 days, recheck 10–14
days, analgesia dispensed per protocol.
What makes it work: consent is documented with the timing — mid-procedure phone consent for extractions is exactly the kind of detail that protects you later. Radiographs, charting, and the anesthesia record are referenced as attachments instead of transcribed.
4. Lameness exam
Lameness notes live or die on the Objective section. "Lame RF" tells the next clinician almost nothing; a graded, localized description lets them measure change.
Patient: "Nova" — 4 y FS Border Collie, 18.2 kg
Visit type: Left hind limb lameness, 2 weeks' duration
S: Owner reports intermittent left hind lameness for ~2 weeks, worse after
agility training, improves with rest. No known trauma. No vocalization.
Otherwise eating and behaving normally. No previous orthopedic history.
O: BAR. T 38.5°C, HR 96, RR panting. Gait: grade 2/5 left hind lameness at
trot, subtle at walk. Standing exam: mild muscle atrophy left thigh
compared to right. Orthopedic exam: full ROM both hips, no pain on hip
extension. Left stifle: mild effusion palpable, discomfort on full
flexion; cranial drawer and tibial thrust negative under conscious exam.
Right stifle unremarkable. Hocks, digits, and lumbar spine non-painful.
Neuro screen: normal conscious proprioception all limbs.
A: Left stifle pathology most likely — differentials: early/partial cranial
cruciate ligament injury (most likely given signalment, effusion, and
activity pattern), patellar luxation (no luxation elicited today), less
likely soft-tissue strain. Hip dysplasia less likely given normal hip
exam, but not excluded without imaging.
P: 1. Discussed findings and differentials with owner.
2. Recommended sedated stifle radiographs ± sedated drawer test to assess
for cruciate injury; owner elected to schedule for later this week.
3. Until then: strict rest (leash walks only, no agility), analgesia
dispensed per protocol.
4. If radiographs support cruciate injury, will discuss surgical referral
vs conservative management at recheck.
What makes it work: the assessment ranks differentials and says why — "most likely given signalment, effusion, and activity pattern." The WSU rubric grades exactly this: differentials "assessed as to what is most likely in this animal and why (as well as what is unlikely and why)." That reasoning is what makes the record defensible if the case goes badly and reviewable if it goes to a specialist.
5. Vomiting and diarrhea
The classic "sick visit" note. The key documentation decision is capturing the owner's timeline precisely — GI histories are 80% of the diagnosis and impossible to reconstruct a week later.
Patient: "Ziggy" — 2 y MN mixed breed, 12.8 kg
Visit type: Acute vomiting and diarrhea
S: Vomited 4x since yesterday evening (food, then bile; no blood). Soft-to-
liquid feces 3x this morning, last one with small amount of fresh blood.
Owner reports patient raided the rubbish bin ~36h ago. Still drinking;
refused breakfast. No known toxin access, no foreign-body history, no
current medications. Fully vaccinated, appropriate parasite prevention.
O: QAR, mildly subdued. T 38.9°C, HR 120, RR 28. Est. 5% dehydrated (tacky
MM, mild skin tent). Abdomen: soft, mild diffuse discomfort on palpation,
no mass or obvious foreign body palpable, no organomegaly. Rectal: liquid
feces, small amount fresh blood, no melena, no foreign material.
A: Acute gastroenteritis, most consistent with dietary indiscretion given
history. Differentials: dietary indiscretion (most likely), GI foreign
body (less likely — no palpable abnormality, but not excluded), infectious
enteritis, pancreatitis (less likely, mild pain only). Mild dehydration.
P: 1. Discussed outpatient vs diagnostic workup with owner, including that a
foreign body cannot be fully excluded on exam alone; owner elected
outpatient trial with clear recheck criteria. Documented.
2. Subcutaneous fluids administered in clinic; antiemetic given per
protocol.
3. Gastrointestinal diet in small frequent meals for 3–5 days.
4. Recheck criteria (given verbally + on discharge sheet): continued
vomiting >24h, lethargy, worsening blood in feces, refusing water —
return immediately for radiographs and bloodwork.
5. Follow-up call scheduled for tomorrow (tech).
What makes it work: the note documents the decision, not just the treatment — the owner chose outpatient care after being told a foreign body wasn't excluded. If Ziggy comes back obstructed tomorrow, the record shows the conversation happened. That single line is worth more than any other sentence in the note.
6. Post-operative recheck
Recheck notes are where copy-paste documentation does the most damage. The WSU guide warns against notes that "copy & paste previous entries or just reiterate a previous SOAP" — a recheck note should document change.
Patient: "Luna" — 7 y FS Domestic Longhair, 4.4 kg
Visit type: 10-day recheck post mass removal (left flank)
S: Owner reports Luna has been comfortable since surgery, wearing cone
consistently, eating and using litter box normally. No licking at
incision observed. All post-op medication courses completed as dispensed.
O: BAR. Weight stable (4.4 kg). Incision left flank: fully closed, no
erythema, swelling, discharge, or dehiscence. Sutures intact. No pain on
gentle palpation around site. Remainder of brief exam unremarkable.
A: 1. Routine healing, day 10 post mass removal — ready for suture removal.
2. Histopathology (received day 6): benign lipoma, margins complete —
previously communicated to owner by phone (see comm log day 6).
P: 1. Sutures removed. Cone can be discontinued.
2. Histopathology result reviewed again with owner in person: benign,
complete margins, no further treatment indicated.
3. Owner advised to monitor site and report any regrowth; routine
wellness schedule resumes.
What makes it work: it's short, and that's correct — this is a normal recheck. The histopath result appears with a pointer to when it was first communicated. Brevity in a normal recheck isn't laziness; padding it would just bury the one thing that matters (healed, benign, done).
7. Euthanasia and quality-of-life visit
The hardest note to write, and one of the most important to write well. It protects you legally, but more than that — it's the last entry in a patient's record, and the family may one day request a copy.
Patient: "Buster" — 14 y MN Beagle, 9.8 kg
Visit type: Quality-of-life consultation → euthanasia
S: Presented with owners (both present) for quality-of-life discussion.
Chronic degenerative joint disease and chronic kidney disease (IRIS
staged, see prior records), both progressing despite management. Owners
report: difficulty rising most mornings, two falls this week, appetite
now <50% of normal despite appetite support, weight loss continuing,
withdrawn from family interaction. Good days now rare per owners.
O: QAR, thin (BCS 3/9, down from 4/9 three months ago). T 38.1°C, HR 104.
Marked muscle wasting hindlimbs. Reluctant to stand; ataxic when
walking. Mucous membranes pale pink. Remainder of exam consistent with
documented chronic conditions.
A: End-stage chronic disease with declining quality of life despite
appropriate management. Clinical picture consistent with owners' report
of poor and worsening quality of life.
P: 1. Quality-of-life discussion held with both owners; prognosis and
options reviewed (continued palliative care vs euthanasia). Owners
elected euthanasia today. Written consent signed (attached).
2. Sedation administered per protocol; owners present throughout.
Euthanasia solution administered IV per protocol. Death confirmed by
absence of heartbeat and corneal reflex at [time].
3. Aftercare: owners elected communal cremation per signed form.
4. Condolence card task assigned; reminders for this patient
deactivated in PMS.
What makes it work: consent, presence, confirmation of death, and aftercare wishes are all explicit. The last line — deactivating reminders — prevents the single most painful administrative error a clinic can make. Put it in the template so it never depends on anyone remembering.
8. Emergency triage
Emergency notes are written fast, often in fragments, sometimes after the fact. The template's job is to make sure the time-critical facts land in the record even on a chaotic shift.
Patient: "Rex" — 3 y MN German Shepherd, 34 kg
Visit type: Emergency — acute abdominal distension
Presented [time]: carried in by owner. Per owner: unproductive retching and
rapidly distending abdomen starting ~1h ago, after evening meal. No known
foreign body access.
Triage O ([time]): obtunded. MM pale, CRT >2s. HR 180, weak femoral pulses.
RR 40, shallow. Abdomen markedly distended, tympanic on percussion left
side. T deferred — straight to treatment area.
A: Presentation consistent with GDV until proven otherwise. Shock —
compensatory/early decompensatory.
P ([times noted per entry]):
1. Owner verbal consent for emergency workup and stabilization on
arrival; written estimate signed at [time].
2. IV access x2, shock-rate fluids initiated per protocol.
3. Right lateral radiograph: gas-distended, compartmentalized stomach —
confirms GDV.
4. Gastric decompression per protocol following stabilization.
5. Owner informed of diagnosis, surgical recommendation, prognosis, and
estimate; consented to surgery at [time]. → see surgical record.
What makes it work: timestamps. In an emergency record, when matters as much as what — for the patient, and for any later review of the case. Note also what's missing: no filler, no repetition of the anesthesia or surgery record it hands off to.
How to turn these into your own templates
The examples above are deliberately fuller than what you'll write on a busy Tuesday. That's what templates are for — you cut, you don't compose. A few rules that make clinic templates actually save time:
- Build one per visit type you see weekly. Wellness, vaccine, dental, sick-GI, lameness, recheck cover most companion-animal appointment books. The AVMA's advice is to start with just one — the visit type you see most — and spend fifteen minutes writing it in your own voice.
- Pre-fill the normal, type the abnormal. A wellness template with a complete normal-findings Objective section means you only edit what's actually abnormal. That's also safer than free-typing: a pre-listed body system you didn't delete is evidence you looked at it.
- Keep the Assessment honest. Templates tempt you to leave boilerplate in the A section. Don't — the assessment is the one section that must be thought, not typed. Even one ranked differential with a "because" beats a pasted list.
- Template the conversations, not just the medicine. Recheck criteria, consent wording, post-op instructions, aftercare options — these repeat far more predictably than clinical findings do, and they're the lines that protect you.
- Let the note match the visit. A 10-day recheck earns four lines; a GDV earns timestamps. The WSU guide's rubric penalizes notes that are "inappropriately long or highly repetitive" just as much as incomplete ones.
The other half of the equation is when the note gets written. A template shortens the writing; it doesn't fix a workflow where notes pile up until closing time. If your drafts routinely wait until the clinic is quiet, that's a workflow problem with its own solutions — we wrote about them in how to stop writing SOAP notes after the clinic closes.
Frequently asked questions
Should every patient visit get a full SOAP note? Every visit gets a note; not every visit needs all four sections at full depth. A nail trim doesn't need ranked differentials. The standard to hold yourself to is the one from Weed's original paper and every vet school since: could a colleague pick up this record cold and safely continue care?
Can I combine the Subjective and Objective sections? Yes — combined "S/O" sections are common and explicitly acknowledged in teaching hospitals, because the line between reported and observed is often blurry. If your team reads it clearly, it's fine.
How much detail is too much? If a sentence doesn't help future-you, a colleague, or a legal reviewer understand what you found, thought, or did — cut it. Long notes aren't safer; complete ones are. The reasoning ("extraction indicated because pulp exposure with periapical pathology") is the detail worth keeping; restated normals from three visits ago are not.
Do these examples work for large animal or herd work? The structure adapts directly — treat the herd as the patient and note denominators ("scouring calves 8/20"). The problem-oriented format was designed to flex this way from the start.