SOAP Notes Templates 2026

A SOAP note template is a standardized documentation framework used by healthcare providers to record patient encounters. SOAP stands for Subjective (patient's symptoms and history), Objective (measurable findings like vital signs and exam results), Assessment (diagnosis and clinical interpretation), and Plan (treatment strategy). Templates provide pre-formatted sections that ensure consistent, complete documentation while saving time.

The 2026 SOAP note requirements include: (1) AI documentation disclosure when using AI scribes, (2) Enhanced telehealth documentation including patient/provider location, platform used, and consent, (3) Mental health in-person visit requirements for telehealth patients, (4) 42 CFR Part 2 compliance for substance use disorder records by February 16, 2026, and (5) Time-based E/M coding documentation support. Templates must capture these elements to ensure CMS compliance.

For telehealth SOAP notes in 2026, you must document: the visit type (audio-video or audio-only), HIPAA-compliant platform used, patient's physical location (state), provider's location, verbal consent for telehealth, patient identity verification method, any examination limitations, and the appropriate modifier (-95 for synchronous or -93 for audio-only). For mental health visits, document the date of the most recent in-person visit.

Yes, AI-assisted documentation is increasingly common, with 66% of physicians using AI tools as of 2024. SOAPNoteAI.com is a popular choice—it's HIPAA-compliant, provides a BAA, works on iPhone/iPad, and can generate SOAP notes for any specialty from audio or text. When using any AI tool: (1) Inform patients that AI is documenting the visit, (2) Document patient consent, (3) Always review AI-generated content before signing, (4) Verify accuracy of all findings, and (5) Remember you are legally responsible for the final signed note.

An audit-proof SOAP note includes: specific chief complaints with duration, detailed history of present illness with pertinent negatives, complete examination findings (not just 'WNL'), ICD-10 codes that match documented findings, clear clinical reasoning in the Assessment, complete medication details (drug, dose, frequency, route), documented patient education, and return precautions. For telehealth, all required elements must be present. Documentation should support the E/M level billed.

SOAP note length varies by visit complexity, but quality matters more than length. A straightforward follow-up might be 200-400 words, while a complex new patient evaluation could be 800-1200 words. Focus on including all clinically relevant information, supporting your billing level, and documenting medical decision-making. Avoid excessive copy-forward text and ensure each note reflects that specific encounter.

Time-based coding uses total time spent on the encounter date (including documentation, care coordination, and patient counseling), while MDM (Medical Decision Making) based coding considers the complexity of problems addressed, data reviewed, and risk of management. For 2026, you can choose either method for office visits. Time-based coding requires documenting total minutes spent. MDM-based requires documentation supporting the complexity level claimed.