SOAP notes
SOAP notes are a structured way to write a veterinary medical record in four parts: Subjective, Objective, Assessment, and Plan.
SOAP is a format for clinical documentation. The letters stand for Subjective, Objective, Assessment, and Plan. Writing exam notes this way keeps records consistent and easy for anyone on the team to follow.
What each part means
- Subjective: what the owner reports and the history
- Objective: measurable findings like temperature, heart rate, and exam observations
- Assessment: the clinical interpretation or differential
- Plan: diagnostics, treatment, and follow-up
Good PIMS software makes SOAP notes fast with templates, so documentation does not slow down the appointment. In OpenVPM, SOAP notes are structured and connected to the rest of the patient record, including labs and prescriptions.
See it in OpenVPM
See how OpenVPM does it
OpenVPM is the open-source veterinary PIMS. Free to self-host, with an open API and your data always exportable. The demo is live, no signup.