Pick a note format and your specialty, switch sections on or off, put them in the order you work, then copy or download a blank template for your EHR. No account, and no patient information: the builder has no text boxes, and nothing leaves your browser.
# SOAP Note Template **Date of service:** **Visit type:** **Clinician:** ## Subjective [Reason for visit, history and symptoms as reported] ## Objective [Exam findings, observations, measurements and results] ## Assessment [Clinical impression and progress since last visit] ## Plan [Next steps, referrals, education and follow-up] --- **Reviewed and signed by:** **Date:**
Each format is a convention for ordering the same clinical thinking. The best one is usually the one your college, payer or program expects, and the one that matches how you work through a visit.
Most medical and surgical specialties
Subjective, Objective, Assessment, Plan. It comes from Lawrence Weed's problem-oriented medical record (1968) and separates what the patient reports from what you observe and measure, then your impression and plan.
Counselling and psychotherapy sessions
Data, Assessment, Plan. It folds the subjective and objective parts of SOAP into one Data section, which suits talk-based sessions where most of the record is what was said and observed in the room.
Addictions, group and skills-based work
Behaviour, Intervention, Response, Plan. It puts the interventions you used and the client's response to them at the centre of the note, which many programs want to see session by session.
Complex or crisis visits
Prose ordered by topic, used when a sectioned format feels forced. The template keeps light headings so the note still covers the reason for the visit, findings, impression and plan.
Replying to a referring clinician
A clinician-to-clinician letter: the referral question restated, pertinent history and findings, your impression, recommendations and who follows up.
A public web page is the wrong place for health information, so the builder only takes choices: a format, a specialty, which sections to include and their order. It has no text boxes, makes no network requests with what you pick, and stores nothing. Fill the template in inside your EHR, where your clinic's privacy safeguards apply. Section structures are starting points based on common documentation conventions; adapt them to your college's and payers' standards.
SpecScribe transcribes the visit and drafts the note in formats like SOAP, DAP, BIRP or narrative, using your specialty's template. You review, edit and sign every note; nothing enters the record until you do.
Book a demoYes. It's free to use, with no account and no sign-up. It runs entirely in your browser.
No. The builder has no text boxes at all: you only pick options, toggle sections and reorder them. Nothing is sent to SpecScribe or saved; the template is built in your browser and disappears when you close the page.
SOAP separates subjective reports from objective findings before the assessment and plan. DAP combines those two into a single Data section, which suits counselling sessions. BIRP centres the note on the interventions used and the client's response, which is common in addictions and group programs.
Usually, yes. Copy the template or download it as Markdown or plain text, then paste it into your EHR's template, macro or smart-phrase editor. How templates are set up varies by EHR, so check its documentation.
They follow widely used documentation conventions, but they are starting points, not regulatory requirements. Check them against your college's and payers' documentation standards and adapt them. General information, not legal advice.
The builder gives you a blank structure. SpecScribe is clinical documentation software: it transcribes the visit and drafts the note in formats like these for you to review, edit and sign. Nothing becomes part of the record until you sign it.
More about SpecScribe: specialty use, pricing and privacy.