SOAP Notes for Veterinarians: Structure, Examples, and Swedish Recommendations

When multiple people are involved in an animal’s care, the medical record must indicate the source of each piece of information, what was actually observed, and the veterinarian’s reasoning. The SOAP model provides a consistent structure for this, and it works both for manually writing medical records and for reviewing AI-generated drafts.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. In Swedish, these components correspond to subjective information, objective findings, assessment, and plan. This article reviews each component, provides an example, and compares SOAP with the order suggested by the industry-wide Swedish recommendations.

S – Subjective: medical history and information provided by the pet owner

The “Subjective” section documents the medical history and information provided by the pet owner or another informant: the reason for the visit, the onset and course of the symptoms, past medical history, current medications, and how the animal is doing at home.

The source of the information must be stated. Phrases such as “according to the animal owner” (according to the owner) or “according to the referring veterinarian” (according to the referrer) distinguish reported information from the clinic team’s own observations. Uncertain time frames and other ambiguities must be reported as such.

O – Objective: Clinical examination and findings

The "Objective" section documents what the veterinarian or clinic team observes, examines, or measures during the visit: general condition, clinical findings, measurements, and the results of diagnostic tests performed.

The notes should indicate what was actually examined and what the examination revealed. A finding must be described with sufficient precision so that another veterinarian can understand the observation, and information that was never verified should not be presented as a finding. The veterinarian’s own findings belong here, even when they confirm what the animal owner has reported.

A – Assessment: evaluation, differential diagnoses, and diagnosis

In the “Assessment” section, the veterinarian summarizes his or her evaluation based on the medical history and objective findings. This section lists current problems, differential diagnoses, the diagnosis when it can be established, and, where relevant, the prognosis and treatment options.

The assessment must be traceable back to the supporting documentation in S and O. If the supporting documentation is insufficient to support a definitive conclusion, the uncertainty must be stated, and a preliminary assessment should be marked as such.

P – Plan: Treatment, Follow-up, and Communication

The "Plan" section documents the treatment that has been administered or prescribed, planned diagnostic tests and follow-up, as well as advice and agreements with the pet owner.

The plan should be specific enough that the next person who reads the medical record will understand what has been decided. If no follow-up is planned, this can also be documented, as long as the wording reflects the veterinarian’s actual decision.

Where does this task belong?

The same question may appear in several sections without the information being identical. A simple rule of thumb:

When a clinical decision is revised during a subsequent visit, the new assessment and the basis for it should be clearly stated in the new note.

Example of a SOAP journal

The example below is fictional and is intended solely to illustrate how the information is presented. It is not a clinical recommendation. The abbreviations follow the suggestions in the Swedish recommendations (see the next section).

S: According to the owner, the dog has been limping on its left hind leg for the past two days; the symptoms began after playing in the woods. TUAD. No current medication.

O: AT, etc. Temp. 38.6 °C. Lameness upon walking; graded according to the clinic’s scale. Palpation: mild swelling and tenderness over the left tarsus. Other variables were not noted at the time of examination.

A: Limping. Suspected soft tissue injury to the left tarsus. Differential diagnosis: sprain, minor fracture. Preliminary assessment.

P: Leashed walks and rest for seven days. Follow-up visit in seven days, or sooner if the condition worsens. An X-ray will be considered if there is no improvement. Note: The pet owner has been informed of the plan and the cost of a possible X-ray.

In addition, a valid medical record entry must include the information required for each examination and treatment—such as the date, time, and the name and title of the person who performed the examination—and must reflect what was actually done during the visit.

SOAP and the Swedish Recommendations for Medical Record Keeping

In 2022, Industry-Wide Recommendations for Veterinary Record-Keeping in Sweden were published, developed by representatives from, among others, SLU, Evidensia, AniCura, Blå Stjärnan, Svensk Djursjukvård, Agria Djurförsäkring, and Distriktsveterinärerna. The recommendations are based on the Swedish Board of Agriculture’s regulations and the GDPR. They are not a government mandate, so sections that do not reference a law or regulation should be considered suggestions. The document is available from the Swedish Veterinary Association.

The recommendations do not use the acronym SOAP, but suggest an order that largely follows the same logic:

The Swedish format is thus more detailed than SOAP, primarily because the problem list, diagnosis, and communication with the pet owner each have their own headings. A clinic that follows the SOAP format can benefit from using the Swedish subheadings within each section.

A few recommendations that are particularly worth noting:

• Timing: The medical record should be written immediately following the consultation. It should normally be signed off on the same day. If that is not possible, the most important details should be documented on the same day, and the record should be signed off on the next business day.
• What was examined: It is not sufficient to write "Clinical examination, n/a" for an entire examination, since it does not specify what was examined. Specify which variables were examined, and write, for example, "Other variables were not assessed at the time of the examination" for the rest.
• Source: The source of the information must be clearly stated, for example, "according to the owner" or "according to the referral."
• Abbreviations: Use only abbreviations that are generally accepted in Sweden. For example, the recommendations introduce the acronym TUAD for thirst, urination, appetite, and defecation when, according to the pet owner, all are normal.
• Medications: When treatment has been initiated, the name, strength, dosage, and duration of treatment must be specified; for food-producing animals, the withdrawal period must also be indicated.
• Personal information: As little personal information about the pet owner as possible should be recorded, and sensitive information such as religion, medical conditions, or political affiliation should never be recorded.

The Swedish Board of Agriculture's own record-keeping requirements are summarized on the page about obligations for animal health personnel.

Common Errors in SOAP Notes

• The pet owner’s information is recorded as separate findings. When the pet owner’s observations are listed under “O,” the reader may assume that the clinic team has confirmed them.
• Findings from the physical examination are included in the medical history. Findings from the physical examination can be difficult to identify when they are mixed in with the pet owner’s account.
• The assessment merely reiterates the findings. Section A should include the veterinarian’s interpretation and conclusion, not a repetition of S and O.
• The plan lacks follow-up. It should be possible to see what happens after the visit and who has agreed to what.
• Default text provides incorrect information. Pre-filled text may make it appear as though certain examinations or recommendations were performed, even though they were not part of the visit.

More common errors in medical records are described in “The Most Common Mistakes in Medical Record Writing.”

SOAP Notes with AI

AI support can generate a structured draft of the medical record based on the conversation during the consultation. The draft is a working document until the responsible veterinarian has reviewed, corrected, and approved it. When reviewing the draft, the SOAP structure is a useful tool: check that the pet owner’s information is listed under “S,” that only findings from the actual examination are listed under “O,” that the assessment is the veterinarian’s own, and that the plan aligns with what was decided.

The AI cannot know information that was never mentioned during the conversation. Findings that the veterinarian noted silently during the examination must therefore be added, for example, by dictating them afterward. The difference between AI that listens to the conversation and AI dictation is described in “AI Dictation for Veterinary Records.”

SOAP Notes in Vetz

Vetz listens during the conversation with the pet owner and creates a draft medical record structured according to the clinic’s procedures. Vetz can be customized to match the clinic’s own medical record templates, so a clinic that follows the SOAP format or the recommended Swedish format can have a template set up for that purpose. The veterinarian reviews and approves the draft before it is transferred to the medical record system.

The workflow is described in “How Vetz Works ” and “AI-Powered Medical Record Keeping for Veterinarians.” An overview of all features is available on the Vetz Features page.

You can try Vetz for free for 14 days. Clinics that want to see how the draft medical records can follow their own template can schedule a demonstration.