What Are Veterinary SOAP Notes?
- CoVet
- 6 days ago
- 6 min read
Updated: 3 days ago
When you’re juggling back-to-back appointments, chasing down lab results, and fielding client calls, clear documentation can slip down the priority list. But when done right, veterinary SOAP notes keep records tidy and make the entire clinic run smoother.
SOAP stands for Subjective, Objective, Assessment, and Plan. It’s the gold standard format for documenting patient visits in veterinary medicine. Whether you're dealing with a straightforward vaccine appointment or a complex lameness case, SOAP notes help structure your thinking, improve communication across the team, and ensure consistent, high-quality care.
The challenge? Writing them takes time. And when time is already tight, that often means catching up after hours, relying on memory, or skipping details altogether. That’s where automation can make a real difference—without cutting corners.
In this article, you'll learn why SOAP notes matter for every veterinary role on your team, how to break down each section effectively, and where AI copilot tools like CoVet fit into your clinic workflow.
Why SOAP notes matter in veterinary practices
When every team member documents in the same structured way, it’s easier to track patient progress, avoid repeat diagnostics, and make sure nothing falls through the cracks during handoffs.
But even though the format is simple, creating efficient SOAP notes isn’t always easy.
Time pressure: With packed schedules, there’s often little time to finish notes between appointments. Many DVMs end up documenting late into the evening or relying on rushed memory recalls.
Inconsistent documentation: Without a shared approach, records can vary dramatically between team members—making it harder to get a clear picture of the patient’s history.
Missed details: When you're multitasking, it's easy to forget a minor symptom or treatment instruction. Over time, those gaps can affect care quality and follow-up decisions.
Structured SOAP notes help solve these problems—but only if they’re used consistently, and without adding extra work. That’s where our tips for SOAP writing and veterinary dictation software come in.
See how structured notes can reduce errors
Breaking down the SOAP format
Each part of a SOAP note serves a clear purpose. When used consistently, the format helps your team communicate clearly, track patient changes over time, and make faster, more informed decisions. Here’s how to approach each section.
Subjective: What the pet owner or team reports
This is where the visit starts. The Subjective section includes any observations shared by the client or your team—things that can’t be measured directly but still offer critical context.
What to include:
Reported symptoms (vomiting, limping, appetite changes)
Behavior changes (hiding, vocalizing, aggression)
Historical details (duration of signs, response to past treatments)
Examples:
“Bella hasn’t eaten for 2 days.”
“Limping on right hind leg since Saturday.”
“Owner reports increased thirst and urination.”
Tips:
Capture the owner’s own words when possible. It improves clarity and helps with client communication later.
Use this section to document technician observations during triage.
Avoid interpreting data here—save diagnoses for the Assessment.
Objective: What you can measure or observe
This section covers facts—anything you or your team can physically observe, measure, or test. It’s the most straightforward part of the note, but getting it right is critical for tracking trends and supporting your assessment.
What to include:
Vital signs (temperature, pulse, respiration)
Physical exam findings (swelling, discharge, masses)
Diagnostic results (in-house labs, radiographs)
Examples:
Temperature: 102.5°F
Mild swelling in right hock
Heart rate: 140 bpm, no murmurs
CBC: mild leukocytosis
Tips:
Stick to facts only—no interpretations or guesses.
If a test was ordered but results are pending, note it here.
Use bullet points for clarity, especially in complex cases.
Assessment: What’s the diagnosis or problem list?
This is where clinical reasoning comes in. The Assessment section summarizes your interpretation of the case so far. It might be a confirmed diagnosis, a list of differentials, or a note about ongoing monitoring.
What to include:
Primary and secondary diagnoses
Differential diagnoses if the case isn’t fully worked up
Notes on current status or progression
Examples:
Suspect soft tissue injury to right hind limb; rule out cruciate ligament tear
Mild dehydration, likely secondary to vomiting
Rule out tick-borne disease due to recent travel and joint swelling
Tips:
If you're still working through differentials, state them clearly. Don’t jump to conclusions.
Use this section to guide the treatment plan and justify next steps.
Keep the language clear—this is what other team members will use to understand your clinical thinking.
Plan: What happens next?
The Plan outlines what you’re doing about the problem. This includes treatments, diagnostics, client communication, and follow-up instructions. It should be actionable and easy for the rest of the team to follow.
What to include:
Medications prescribed or administered
Additional tests or imaging
Client instructions for home care
Timeline for follow-up or recheck
Examples:
Rimadyl 25mg BID for 5 days; dispense 10 tabs
X-rays of right stifle scheduled for tomorrow
Client advised to restrict activity; recheck in 3 days
Monitor hydration status; consider SQ fluids if no improvement
Tips:
Be specific. “Recheck” means nothing unless it’s tied to a timeframe or purpose.
Include who is responsible for each follow-up (e.g., “Tech to call client in 2 days”).
Document what you told the client, especially if they declined a recommendation.
How CoVet helps automate SOAP note-taking
Even when you know what a great SOAP note looks like, writing them during a packed clinic day is another story. CoVet steps in—not as a replacement, but as a second set of hands that never misses a detail.
Here’s how CoVet fits into your daily workflow:
Real-time voice capture
CoVet listens as you talk—during or after the appointment—and automatically generates draft notes in the proper SOAP format. You don’t need to repeat yourself or summarize after the fact. Just speak naturally, and the AI handles the structure.
Role-specific customization
Whether you’re a DVM, technician, or client care specialist, CoVet adapts to your role. You get what you need—without being overwhelmed by details that aren’t relevant to your part of the case.
Built-in PIMS integration
No double entry, no extra tabs. CoVet syncs directly with your practice management software, so finalized notes go exactly where they belong.
Standardization across the team
By guiding everyone to document using the same structure and language, CoVet helps reduce variability in records. That means fewer follow-up calls, better compliance, and smoother team handoffs.
Details don’t get dropped
When notes are created in real time, you capture more nuance. That builds client trust, supports better medicine, and helps keep the whole care team aligned. Plus, in case you didn't get a recording, you can upload patient histories in PDF format (or even photos of hand-written notes) and get a concise summary in seconds.
Better documentation for every care team
In a busy general practice, it’s easy for documentation to become an afterthought. But SOAP notes aren’t just for compliance. They’re a tool to deliver better medicine, reduce miscommunication, and protect your time. When they’re structured and consistent, your whole team benefits.
With CoVet, you don’t need to trade off between quality and speed. By automating the SOAP process and integrating directly with your PIMS, CoVet helps you capture accurate, complete records—right when the care is happening. That means fewer late nights, fewer missed details, and more time for what actually matters: the patient in front of you. Plus, when looking at veterinary scribe pricing comparison, CoVet offers a powerful, cost-effective alternative without compromising on quality.
Put your notes on autopilot
Frequently asked questions about vet SOAP notes
What's an example of a vet SOAP note?
A typical SOAP note might include the chief complaint, history of present illness, objective data from the physical examination, and a plan for diagnostic tests. For example, veterinarians may list gastroenteritis or note pale mucous membranes.
Check out this our guide on practical tips, common mistakes to avoid, and a downloadable SOAP template PDF to make documentation easier.
What do veterinary SOAP notes look like?
What tools can I use to create veterinary AI SOAP notes?
