SOAP Note Example for a Telehealth UTI Visit

Updated June 2026 · Doctor Notes

A SOAP note for a telehealth UTI visit should include details on the patient's symptoms, relevant data from their history, physical examination findings, and a clear plan for management. This structured approach ensures comprehensive documentation and effective patient care.

What is a SOAP note?

A SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart. SOAP stands for Subjective, Objective, Assessment, and Plan. This format helps ensure all relevant information is captured and organized systematically.

How to document the Subjective section?

The Subjective section includes the patient's reported symptoms and history. For a telehealth UTI visit, you might document:

Chief Complaint: "Burning sensation during urination and increased frequency."
History of Present Illness: "The patient reports a 3-day history of dysuria and urinary frequency. No fever or flank pain reported."
Past Medical History: "No previous UTIs. No history of kidney stones or diabetes."
Medications: "Currently taking oral contraceptives. No antibiotics recently."
Allergies: "No known drug allergies."

What should be included in the Objective section?

In a telehealth setting, the Objective section is limited to observations made during the video consultation and any data the patient can provide:

General Appearance: "Patient appears comfortable and in no acute distress."
Vital Signs: "Patient reports a temperature of 98.6°F, no access to blood pressure or pulse rate at home."
Other Observations: "No visible signs of distress or discomfort during the consultation."

How to write the Assessment section?

The Assessment section includes your clinical impression based on the Subjective and Objective findings. For a UTI, it might read:

"Uncomplicated urinary tract infection likely, based on symptoms of dysuria and frequency without systemic symptoms."

What should the Plan section contain?

The Plan section outlines the management strategy and follow-up. For a telehealth UTI visit, this could include:

Prescriptions: "Prescribe Nitrofurantoin 100 mg orally twice daily for 5 days."
Patient Education: "Advise increased fluid intake and complete the full course of antibiotics."
Follow-up: "Schedule a follow-up telehealth visit in 7 days or sooner if symptoms worsen."

Why is using SOAP notes important in telehealth?

SOAP notes are crucial in telehealth as they provide a structured way to document patient interactions remotely. They ensure that all necessary information is captured, facilitating continuity of care and accurate communication between healthcare providers.