Complete Guide to Follow Up SOAP Note Examples for Healthcare Providers

If you've ever wondered what makes a follow-up visit note different from an initial visit, or struggled to document ongoing care efficiently, this guide is for you.

I've talked to countless physicians, nurse practitioners, and physician assistants who tell me the same thing: follow-up notes feel repetitive, yet they can't just copy-paste from previous visits.

Insurance companies scrutinize follow-up documentation carefully because this is where they look for evidence that ongoing treatment is working, necessary, and properly managed.

The reality is that follow-up SOAP notes have unique requirements that go beyond initial visit documentation.

They need to show clinical progression, treatment response, medication adjustments, and justification for continued care.

That's exactly why I built SOAP Notes Doctor to streamline follow-up documentation while ensuring you capture everything insurance companies want to see.

In this article, I'll show you exactly how to write follow-up SOAP notes that demonstrate continuity of care and meet insurance standards, with real examples you can use as templates.

🧾 What Makes Follow-Up SOAP Notes Different

Follow-up notes aren't just shorter versions of initial visit notes.

They serve a distinct purpose in your patient's medical record.

While initial visit notes establish the baseline and create the treatment plan, follow-up notes demonstrate:

• Treatment efficacy: Is the intervention working?
• Clinical progression: Is the patient improving, stable, or declining?
• Medication response: Are there side effects or necessary adjustments?
• Compliance assessment: Is the patient following the treatment plan?
• Medical necessity: Does ongoing care remain justified?

For follow-up visits specifically, SOAP notes are critical because they demonstrate:

• Clear comparison to previous visits and baseline status
• Response to prescribed treatments or interventions
• Appropriate monitoring of chronic conditions
• Medical necessity for continued medications or therapies
• Justification for specialist care or advanced testing

The SOAP structure still applies:

• S — Subjective: How the patient reports feeling since last visit, symptom changes, medication tolerance, and compliance.
• O — Objective: Current clinical findings with explicit comparison to previous visits (vitals, exam changes, lab trends).
• A — Assessment: Clinical status compared to baseline, treatment response evaluation, and risk reassessment.
• P — Plan: Continued treatment, adjustments based on response, new interventions if needed, and clear follow-up timeline.

This structure keeps your follow-up documentation organized, shows clinical reasoning, and proves medical necessity for ongoing care.

How You Can Approach Follow-Up SOAP Notes

There's no single correct method for writing follow-up SOAP notes, but some approaches work better than others depending on your practice volume.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: reviewing previous notes, comparing findings, and typing out each section after each visit. It works if you have excellent recall and consistent time built into your schedule. The challenge is it's time-consuming, especially when you need to reference multiple previous visits to show trends.

2. SOAP Notes Doctor

You record your examination findings or dictate key observations including changes from last visit, and the tool automatically structures everything into proper follow-up SOAP format. It can reference previous visit data, highlight changes automatically, and ensure consistency across multiple follow-ups for the same patient.

How to Make Follow-Up SOAP Notes Faster

One of the biggest complaints I hear from providers is that follow-up notes feel like they take just as long as initial visit notes, even though the visit itself is shorter.

You've just seen 20 established patients in a morning clinic, each needing their medication refilled, labs reviewed, or chronic condition monitored, and instead of moving on to the next task, you're stuck typing notes that feel repetitive yet can't actually be copied.

The pressure is real: make them too brief and you risk insurance denials for continued prescriptions or specialist referrals; make them too detailed and you've just added hours to your workday documenting visits that only took 10 minutes.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your key findings and changes from last visit
✅ Generate properly formatted follow-up SOAP notes instantly
✅ Get your time back without sacrificing quality

With soapnotes.doctor, you can quickly dictate the essentials: "BP improved to 128/82, down from 142/90 last visit. Patient tolerating lisinopril well, no cough or dizziness. Continue current dose, recheck in 3 months."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Hypertension Follow-Up After Medication Initiation

Patient: 54-year-old male
Chief Complaint: Follow-up for newly diagnosed hypertension
Last Visit: 6 weeks ago, started on lisinopril 10mg daily
Visit: Follow-up to assess treatment response

S – Subjective:

Patient returns for blood pressure follow-up after starting lisinopril 10mg daily 6 weeks ago. Reports taking medication consistently every morning, has not missed any doses. Denies any side effects including cough, dizziness, or lightheadedness. Checked blood pressure at home twice weekly with average readings 128-135/80-86. Reports these readings are lower than pre-treatment readings which were consistently 145-150/90-95. Denies headaches, chest pain, or visual changes. Lifestyle modifications ongoing including reduced sodium intake and walking 30 minutes 4-5 times weekly. No new concerns or symptoms since last visit.

O – Objective:

Vital Signs: BP 130/84 (baseline at diagnosis 148/94, 6 weeks ago 146/92), HR 68, Weight 192 lbs (unchanged from last visit)
General: Well-appearing, no acute distress
Cardiovascular: Regular rate and rhythm, no murmurs, peripheral pulses intact
Labs: BMP today shows Na+ 140 mEq/L, K+ 4.1 mEq/L, Creatinine 1.0 mg/dL (baseline 0.9)

A – Assessment:

54-year-old male with essential hypertension, improved on lisinopril 10mg daily. Blood pressure approaching goal of less than 130/80. Patient demonstrating good medication compliance and lifestyle modification adherence. Tolerating ACE inhibitor without side effects. Renal function and electrolytes stable on current therapy. Overall excellent response to initial management.

P – Plan:

Continue lisinopril 10mg daily. Patient to continue home blood pressure monitoring twice weekly and maintain log. Continue lifestyle modifications including low-sodium diet and regular exercise. Recheck BP and BMP in 3 months. If blood pressure remains at goal, can extend follow-up interval to 6 months. Patient instructed to contact office if develops persistent cough, swelling, dizziness, or BP readings consistently above 140/90. Refilled lisinopril for 90 days. Patient verbalized understanding and agreement with plan.

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Example 2: Diabetes Follow-Up with A1C Check

Patient: 62-year-old female with Type 2 Diabetes
Chief Complaint: Routine diabetes follow-up
Last Visit: 3 months ago, metformin dose increased to 1000mg twice daily
Visit: Follow-up for diabetes management and A1C review

S – Subjective:

Patient returns for 3-month diabetes follow-up. Reports improved glucose control since metformin dose increase. Home glucose readings now averaging 110-140 fasting and 140-170 post-meal (previously 150-180 fasting). Taking metformin 1000mg twice daily with meals, tolerating well with no GI upset. Following diabetic diet with carbohydrate counting, meeting with dietitian monthly. Walking 20 minutes daily. Denies polyuria, polydipsia, or polyphagia. Vision stable, no foot numbness or tingling. Compliant with daily foot checks.

O – Objective:

Vital Signs: BP 128/76, HR 74, Weight 178 lbs (down 4 lbs from last visit), BMI 29.8
General: Alert, appropriate mood
HEENT: Visual acuity intact, no retinopathy noted on recent eye exam
Cardiovascular: Regular rate and rhythm
Extremities: Feet intact, no ulcers or calluses, monofilament sensation intact bilaterally, pedal pulses 2+ bilaterally
Labs: A1C 7.2% (down from 8.1% three months ago), Fasting glucose 118 mg/dL, Creatinine 0.9 mg/dL, eGFR greater than60, urine microalbumin 18 mg/g (normal)

A – Assessment:

62-year-old female with Type 2 Diabetes Mellitus showing significant improvement in glycemic control on current regimen. A1C decreased from 8.1% to 7.2% over past 3 months, approaching goal of less than 7%. Patient demonstrates excellent medication compliance and lifestyle modification adherence with 4-pound weight loss. No evidence of diabetic complications including retinopathy, nephropathy, or neuropathy. Current management effective.

P – Plan:

Continue metformin 1000mg twice daily. Given progress toward A1C goal, will continue current regimen without medication changes. Patient to continue home glucose monitoring twice daily (fasting and 2-hour post-dinner). Continue diabetic diet and exercise program. Encouraged continued weight loss with goal of 5-10% body weight reduction. Annual diabetic foot exam completed today, next due in 12 months. Eye exam current (completed 2 months ago), next due in 10 months. Consider adding GLP-1 agonist if A1C not below 7% at next visit. Follow-up in 3 months with repeat A1C and metabolic panel. Patient verbalized understanding of plan and goals.

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Example 3: Depression Follow-Up After Starting Antidepressant

Patient: 38-year-old female
Chief Complaint: Follow-up for major depressive disorder
Last Visit: 4 weeks ago, started sertraline 50mg daily
Visit: Follow-up to assess medication response and side effects

S – Subjective:

Patient returns for depression follow-up after starting sertraline 50mg daily 4 weeks ago. Reports noticeable improvement in mood over past 2 weeks. Feels "more like herself," with improved motivation and energy. No longer crying daily, able to enjoy time with children. Sleep improved, now sleeping 6-7 hours nightly (previously 4-5 hours with early morning awakening). Appetite normalizing. Reports mild nausea during first week of medication which has now resolved. Denies any worsening of depression, no suicidal ideation or self-harm thoughts. PHQ-9 score today: 8 (down from 18 at last visit). Attending therapy weekly and finds it helpful. Denies manic symptoms including decreased need for sleep, racing thoughts, or impulsivity.

O – Objective:

Vital Signs: BP 118/72, HR 76, Weight 142 lbs (stable)
General: Appropriate dress and grooming, good eye contact, engaged in conversation
Psychiatric: Mood euthymic, affect brighter and more reactive compared to last visit, speech normal rate and volume, thought process linear and goal-directed, denies suicidal ideation with plan or intent, no homicidal ideation
PHQ-9: 8 (mild depression, previously 18 indicating moderately severe depression)

A – Assessment:

38-year-old female with major depressive disorder, single episode, responding well to sertraline 50mg daily. Significant improvement in depressive symptoms evidenced by PHQ-9 score reduction from 18 to 8. Patient tolerating medication well with resolution of initial GI side effects. Sleep, appetite, and energy improving. No safety concerns, patient remains engaged in psychotherapy. Current dose appears therapeutic but not yet at full remission (PHQ-9 goal less than 5).

P – Plan:

Continue sertraline 50mg daily for now given positive response and good tolerability. Will consider uptitration to 75-100mg if symptoms plateau or do not continue improving toward remission. Patient to continue weekly psychotherapy sessions. Discussed that full medication response may take 6-8 weeks. Reinforced importance of medication compliance. Reviewed safety planning and provided crisis hotline number. Patient to continue monitoring mood and sleep patterns. Follow-up in 4 weeks to reassess symptoms with repeat PHQ-9 screening. If continued improvement, can extend follow-up interval to 8-12 weeks. Patient instructed to contact office immediately if worsening depression, suicidal thoughts, or concerning side effects develop. Refilled sertraline for 60 days. Patient verbalized understanding and agreement with plan.

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Key Components Insurance Companies Look For in Follow-Up SOAP Notes

When reviewing your follow-up documentation, insurance companies specifically want to see:

1. Explicit Comparison to Previous Visits

Don't just document current findings—show how they compare to baseline or last visit. "BP 130/84, down from 148/94 at diagnosis" is much stronger than just "BP 130/84."

2. Treatment Response Documentation

Clearly state whether interventions are working, partially working, or not working. This justifies continuing, adjusting, or changing treatment.

3. Medication Compliance and Tolerance

Document that patient is taking medications as prescribed and how they're tolerating them. Side effects or non-compliance explain why treatment may not be working.

4. Objective Measures of Progress

Use quantifiable metrics: A1C trends, blood pressure readings, PHQ-9 scores, weight changes, pain scales. Numbers prove medical necessity better than subjective descriptions alone.

5. Justification for Continued Care

Why does this patient need to come back? What are you monitoring? What could go wrong if they don't follow up? Make this explicit.

6. Clear Follow-Up Timeline

Document when the patient should return and why that interval is appropriate (not too soon, not too distant).

What Makes a Strong Follow-Up Note vs. a Weak One

Weak Follow-Up Note:

"Patient here for diabetes follow-up. Blood sugar controlled. Continue metformin. Follow-up in 3 months."

Problems: No comparison to previous visits, no specific data, no assessment of how well controlled, no justification for continued treatment or follow-up interval.

Strong Follow-Up Note:

"Patient returns for diabetes follow-up 3 months after metformin dose increase to 1000mg BID. A1C improved from 8.1% to 7.2%, approaching goal of less than7%. Home glucose logs show average fasting 110-140 (previously 150-180). Patient tolerating metformin well without GI side effects. Continue current regimen given excellent response. Repeat A1C in 3 months to assess if goal achieved; if so, may extend interval to 6 months."

Why it works: Shows clear comparison, documents treatment response with objective data, explains reasoning for continuing current therapy, and justifies follow-up timing.

Common Mistakes to Avoid in Follow-Up Notes

Not Comparing to Previous Visits: If you don't show trends, insurance won't know if treatment is working or if continued care is necessary.

Copying and Pasting: Identical notes across multiple visits raise red flags that patient isn't actually being assessed properly.

Missing Medication Changes: If you adjust doses or add medications, document why based on objective findings or reported symptoms.

No Time Reference: Always include when the patient was last seen and what happened at that visit.

Forgetting Compliance Assessment: If treatment isn't working, document whether non-compliance could be a factor.

Vague Plans: "Continue current management" without specifics about what you're continuing and why doesn't demonstrate medical decision-making.

No Safety Net: Especially for chronic conditions, document what should prompt the patient to call or be seen sooner.

Tips for Efficient Follow-Up Documentation

Reference Previous Notes Explicitly

"Since starting lisinopril 6 weeks ago..." or "A1C decreased from 8.1% to 7.2%..." shows you reviewed the chart and are providing continuous care.

Use Objective Measures

Numbers are your friend: lab values, vital sign trends, validated screening scores (PHQ-9, GAD-7, pain scales). They prove medical necessity objectively.

Document Your Clinical Reasoning

Explain why you're continuing, changing, or stopping treatment based on the patient's response. Insurance reviewers want to see your thought process.

Be Specific About the Follow-Up Plan

Not just "follow up in 3 months" but "follow up in 3 months to recheck A1C and assess if goal achieved, at which point may extend interval to 6 months if stable."

Front-Load Important Information

Put the most critical comparison data early in each section so reviewers don't have to hunt for it.

Final Thoughts

Follow-up SOAP notes don't need to be lengthy, but they do need to tell a story.

They need to show progression, justify continued treatment, and demonstrate that you're actively managing your patient's condition.

The key is having a system that efficiently captures comparisons and trends without making you feel like you're rewriting the same note over and over.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that proves medical necessity and continuity of care.

Your follow-up visits are where you actually make the difference in chronic disease management—your notes should reflect that expertise.

That's exactly why we built this tool.

Try it out, see how much time you get back on your follow-up documentation, and let me know what you think.

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