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Free veterinary SOAP note generator
Turn consult shorthand into a veterinary SOAP note with signalment, a clear split between owner history and your findings, and a plain-language summary for the owner.
How to use it
- 01
Start with the signalment
Species, breed, age, sex and neuter status, and today’s weight. Weight matters for every dose in the plan.
- 02
Separate owner report from findings
Write what the owner told you, then your clinical exam (TPR, mucous membranes, hydration) and diagnostics.
- 03
Add plan and consent
Treatment with doses in mg/kg, what the owner agreed to and how you will update them. The draft adds a short summary the owner can read.
What goes in a veterinary SOAP note?
Veterinary SOAP notes follow the same logic as medical ones, with two important differences: they start with the signalment, and the history comes from the owner rather than the patient. This version also ends with a short summary written for the owner, which can be shared after the consult.
- Signalment
- Species, breed, age, sex and neuter status, and weight.
- Subjective (owner report)
- The presenting complaint and history as the owner describes it: onset, appetite, drinking, vomiting, stool, behaviour and possible exposures.
- Objective
- Clinical examination including temperature, heart and respiratory rate, mucous membranes, CRT, hydration, body condition, and diagnostic results.
- Assessment
- Problem list and working diagnosis, with differentials where relevant.
- Plan
- Diagnostics, treatment with drug, dose, route and frequency, procedures, owner consent and estimate, and follow-up.
- Summary for the owner
- A short, plain-language explanation of what was found and what happens next.
Veterinary SOAP note example: suspected intestinal foreign body
Signalment
Dog, Labrador Retriever, 6 years, male neutered, 32.4 kg.
Subjective (owner report)
Vomited three times since yesterday, most recently 4 hours ago. A corn cob went missing from the bin on Sunday. Still drinking but lethargic. No diarrhoea and no stool passed today.
Objective
Quiet, alert and responsive. Temperature 39.1 °C, heart rate 110 bpm, respiratory rate 28 per minute. Mucous membranes pink, CRT under 2 seconds. Approximately 5% dehydrated. Cranial abdominal pain on palpation; no mass palpable. Abdominal radiographs, two views: gas-dilated proximal small intestinal loops, suspicious for a foreign body.
Assessment
Suspected small intestinal foreign body obstruction (corn cob).
Plan
Findings discussed with the owner; consent given for exploratory laparotomy today, and the estimate was given and accepted. IV fluids (Hartmann’s) at twice maintenance. Methadone 0.2 mg/kg IV as premedication. Nil by mouth. Owner to be phoned after surgery.
Summary for the owner
Your dog has been sick because something, most likely the missing corn cob, seems to be stuck in his intestine. The X-rays show his gut is blocked and swollen with gas. We will operate today to find and remove it. He is on a drip to replace the fluid he has lost and has been given pain relief. We will call you as soon as the surgery is finished.
Need the diagnosis code too? Search ICD-10-CM codes
Tips for veterinary SOAP notes
- Weigh the animal at every visit and record the weight in the signalment; all doses depend on it.
- Write doses as mg/kg with route and frequency, and the total amount given where relevant.
- Keep the owner’s account separate from your findings, especially for possible toxin or foreign body exposures.
- Document owner consent and the estimate discussed for procedures, and who gave consent.
- Record pertinent negatives from the history, such as no diarrhoea or normal drinking.
Frequently asked questions
What is signalment?
Signalment is the patient’s basic identity in veterinary notes: species, breed, age, sex and neuter status, and weight. It comes first because it shapes differentials and dosing.
Will it calculate drug doses?
No. It records doses exactly as you wrote them and never calculates or adds one. Always check doses against the animal’s weight before saving the note.
Can I share the owner summary with the client?
Yes, that is what it is for. Read it first to make sure it says what you want the owner to know, then copy it into your discharge or client communication.
Does it work for cats, horses and exotics?
Yes. Write the species and your findings as usual; the structure is the same.
Is it free?
Yes. You can write up to 10 notes a day without an account.
Is it safe to paste case information?
Paste clinical details only, never names, ID numbers or contact details. The text is sent to our AI provider to write the note and is not saved by Docdemic.