Veterinary SOAP Note Examples: 5 Real Cases with AI-Generated Notes (2026)

How These Examples Were Generated

Each of the following SOAP notes was created using VetGeni's voice-to-documentation workflow. The veterinarian spoke their clinical findings into VetGeni, and the AI transcribed the audio, extracted clinical data, and generated a structured SOAP note. The entire process takes approximately 2 to 3 minutes per note, compared to the 12 to 15 minutes typically required for manual documentation. That is approximately 10 minutes saved per SOAP note.

VetGeni's AI is powered by Wiley-licensed veterinary references, which means drug doses, differential diagnoses, and treatment recommendations are grounded in peer-reviewed clinical literature. This is what separates VetGeni from generic AI tools that generate plausible but unverifiable medical content.

Case 1: Canine Annual Wellness Exam

Patient: “Bella,” 4-year-old FS Golden Retriever, 31.2 kg

S (Subjective): Owner presents Bella for annual wellness exam and vaccinations. Owner reports Bella is doing well at home. Eating and drinking normally. No vomiting, diarrhea, coughing, or sneezing. Activity level is normal. Owner notes Bella has been scratching her ears occasionally over the past two weeks but no head shaking or odor. Currently on monthly heartworm and flea/tick prevention (Simparica Trio). No current medications otherwise.

O (Objective): T: 101.4 F, HR: 88 bpm, RR: 20 brpm, BW: 31.2 kg (BCS 6/9). General: BAR, well-hydrated, good body condition. EENT: Eyes clear, no discharge. Ears: mild erythema bilateral pinnae, scant brown waxy debris AU, no malodor. Oral: mild tartar accumulation on upper premolars, no gingivitis. Cardiovascular: NSR, no murmurs or arrhythmias. Respiratory: Clear lung sounds bilaterally. Abdominal: Soft, non-painful, no organomegaly. Musculoskeletal: Ambulatory x4, normal gait, no joint effusion. Integument: Coat in good condition, no lesions, no ectoparasites. Lymph nodes: WNL. Neurological: Appropriate mentation, normal PLR bilaterally.

A (Assessment): 1. Healthy adult canine presenting for annual wellness. 2. Mild bilateral otitis externa, likely ceruminous. 3. Mild dental tartar (Grade 1). 4. BCS 6/9, mildly overweight.

P (Plan): 1. Administered DA2PP and Rabies vaccinations. 2. Heartworm/Ehrlichia/Lyme/Anaplasma 4Dx test submitted, results pending. 3. Ear cytology performed AU: yeast and cerumen, no bacteria or mites. Prescribed Otomax otic suspension, 8 drops each ear BID x 10 days. 4. Discussed weight management: reduce daily food by 10%, increase daily walks. Recheck weight in 8 weeks. 5. Recommended dental prophylaxis within next 6 months. 6. Continue Simparica Trio monthly. Annual recheck in 12 months.

Case 2: Canine Acute GI (Vomiting and Diarrhea)

Patient: “Max,” 2-year-old MN Labrador Retriever, 34.5 kg

S (Subjective): Owner presents Max for acute onset vomiting and diarrhea starting approximately 18 hours ago. Three episodes of vomiting, initially food then bilious. Two episodes of watery diarrhea with some mucus, no frank blood noted. Decreased appetite since onset. Still drinking water but vomited after last drink. Owner reports Max got into the garbage approximately 24 hours ago and ingested unknown table scraps. No access to toxins, foreign bodies, or medications. Up to date on vaccinations. No travel history.

O (Objective): T: 102.1 F, HR: 110 bpm, RR: 24 brpm, BW: 34.5 kg (BCS 5/9). General: QAR, approximately 5% dehydrated based on mild skin tenting and slightly tacky mucous membranes. CRT 2 seconds. EENT: WNL. Cardiovascular: Mild tachycardia, no murmurs. Respiratory: Clear bilaterally. Abdominal: Tense on palpation, mild diffuse discomfort, increased borborygmi, no palpable foreign body or organomegaly. Rectal: Loose brown stool, no melena, no hematochezia. Integument: WNL. Neurological: Appropriate.

A (Assessment): 1. Acute gastroenteritis, likely dietary indiscretion (garbage ingestion). 2. Mild dehydration (approximately 5%). 3. Rule out foreign body ingestion, pancreatitis, infectious enteritis.

P (Plan): 1. Abdominal radiographs (2-view): no evidence of obstruction or foreign body. Gas pattern consistent with enteritis. 2. cPL SNAP test: negative. 3. IV fluid therapy: LRS at 80 mL/hr for 4 hours, then reassess hydration. 4. Maropitant (Cerenia) 1 mg/kg SQ once daily. 5. NPO for 6 hours, then offer small amounts of bland diet (boiled chicken and rice) every 4 hours. 6. Metronidazole 15 mg/kg PO BID x 5 days if diarrhea persists beyond 48 hours. 7. Monitor for continued vomiting, worsening lethargy, or bloody stool. Recheck in 48 hours if not improving. ER if vomiting becomes uncontrollable or lethargy worsens.

Case 3: Canine Orthopedic (Cranial Cruciate Rupture)

Patient: “Duke,” 6-year-old MN Rottweiler, 45.8 kg

S (Subjective): Owner presents Duke for progressive left hind limb lameness over the past 3 weeks. Initially intermittent, now consistently non-weight bearing after play. Owner reports hearing a pop 3 weeks ago during fetch in the backyard. Mild improvement with rest but lameness returns with activity. No history of trauma otherwise. No prior orthopedic issues. Currently receiving no medications.

O (Objective): T: 101.6 F, HR: 96 bpm, RR: 18 brpm, BW: 45.8 kg (BCS 7/9). General: BAR, overweight. Musculoskeletal: Grade 3/5 left hind limb lameness at walk. Left stifle: moderate joint effusion, positive cranial drawer test, positive tibial thrust. Medial buttress palpable. Pain on full flexion and extension. Right stifle: no effusion, negative drawer, negative tibial thrust. No concurrent hip or hock abnormalities. Remainder of physical exam WNL.

A (Assessment): 1. Left cranial cruciate ligament rupture, complete, based on positive drawer and tibial thrust with joint effusion. 2. Probable secondary meniscal involvement given medial buttress and duration. 3. Overweight (BCS 7/9), contributing to joint stress.

P (Plan): 1. Left stifle radiographs (2-view): joint effusion confirmed, no fractures, mild periarticular osteophytes consistent with early DJD. 2. Discussed surgical options: TPLO recommended given breed, size, and activity level. Referral to surgical specialist Dr. [name] at [facility]. Appointment scheduling in progress. 3. Pending surgery: strict rest, leash walks only for elimination. 4. Carprofen 2.2 mg/kg PO BID with food x 14 days for pain management. 5. Tramadol 3 mg/kg PO BID x 14 days for breakthrough pain. 6. Initiated weight management discussion: target weight 40 kg, reduce kibble by 15%, eliminate treats. 7. Recheck with surgeon for pre-surgical consult within 2 weeks.

Case 4: Canine Dermatology (Allergic Dermatitis)

Patient: “Sadie,” 3-year-old FS French Bulldog, 11.8 kg

S (Subjective): Owner presents Sadie for chronic pruritus and recurrent skin infections. Symptoms have been present intermittently for the past year but have worsened significantly over the past 6 weeks. Sadie is constantly licking her paws, rubbing her face on furniture, and scratching at her ventral abdomen. Owner has noted a musty odor and brown discharge between skin folds. Prior treatment with oral cephalexin provided temporary improvement. No flea prevention currently. Diet is a commercial chicken-based kibble. No seasonal pattern identified by owner.

O (Objective): T: 101.2 F, HR: 120 bpm, RR: 22 brpm, BW: 11.8 kg (BCS 6/9). General: BAR, mildly overweight. Integument: Diffuse erythema ventral abdomen, axillae, and interdigital spaces bilaterally. Bilateral periocular erythema. Facial fold dermatitis with moist, malodorous exudate. Saliva staining all four feet. Multiple papules and pustules ventral abdomen. Alopecic patches bilateral flanks. Skin scraping: negative for Demodex, Sarcoptes. Impression cytology (ventral abdomen): cocci bacteria, Malassezia yeast. Ear cytology: bilateral moderate Malassezia, mild cocci. EENT: Bilateral otitis externa with brown waxy discharge. Remainder of exam WNL.

A (Assessment): 1. Atopic dermatitis, probable, based on distribution pattern (face, feet, axillae, ventral), breed predisposition, age of onset, and chronic relapsing course. 2. Secondary bacterial pyoderma (superficial) and Malassezia dermatitis. 3. Bilateral Malassezia otitis externa. 4. Facial fold dermatitis. 5. Rule out food adverse reaction, contact allergy.

P (Plan): 1. Cephalexin 22 mg/kg PO BID x 21 days for secondary pyoderma. 2. Ketoconazole 5 mg/kg PO once daily x 14 days for Malassezia. 3. Oclacitinib (Apoquel) 0.4-0.6 mg/kg PO BID x 14 days, then once daily for pruritus control. 4. Otomax otic suspension 8 drops each ear BID x 14 days. 5. Chlorhexidine mousse applied to affected areas every other day. 6. Facial folds: clean daily with chlorhexidine wipe, dry thoroughly. 7. Initiated Simparica Trio monthly for flea/tick prevention. 8. Discussed elimination diet trial: novel protein diet (Royal Canin HP) for 8 weeks. Nothing else by mouth except prescribed diet and medications. 9. Recheck in 3 weeks to assess response. If pruritus persists after elimination diet, discuss allergy testing and immunotherapy.

Case 5: Canine Toxicology (Chocolate Ingestion)

Patient: “Cooper,” 5-year-old MN Beagle, 12.3 kg

S (Subjective): Owner presents Cooper to ER after ingesting approximately 8 ounces of dark baking chocolate (85% cacao) approximately 1 hour ago. Owner found the empty wrapper and estimates the amount based on what was remaining in the package. Cooper has vomited once since ingestion, producing chocolate-colored vomitus. Currently restless and hyperactive. No previous toxin exposures. Otherwise healthy, up to date on vaccinations.

O (Objective): T: 102.8 F, HR: 160 bpm, RR: 36 brpm, BW: 12.3 kg. General: BAR, anxious, hyperactive, panting. Cardiovascular: Tachycardia, regular rhythm, no murmurs. Occasional PVCs noted on auscultation. Abdomen: Soft, non-painful, borborygmi present. Neurological: Hyperexcitable, mild muscle tremors. Remainder of exam unremarkable. ECG: Sinus tachycardia at 160 bpm with occasional ventricular premature complexes.

A (Assessment): 1. Theobromine/caffeine toxicosis secondary to dark chocolate ingestion. Estimated theobromine dose: approximately 130 mg/kg (toxic dose begins at 20 mg/kg for GI signs, 40-50 mg/kg for cardiac signs, greater than 60 mg/kg for seizures). This is a significant ingestion requiring aggressive treatment. 2. Tachycardia with PVCs secondary to methylxanthine toxicity. 3. Mild hyperthermia.

P (Plan): 1. IV catheter placed, LRS at maintenance rate. 2. Apomorphine 0.03 mg/kg IV for emesis induction: productive emesis, large amount of dark chocolate material recovered. 3. Activated charcoal with sorbitol 1-2 g/kg PO via syringe following emesis. 4. Continuous ECG monitoring for arrhythmias. Lidocaine 2 mg/kg IV slow bolus available if sustained VT develops. 5. Maropitant (Cerenia) 1 mg/kg IV for post-emetic nausea. 6. Serial vitals every 30 minutes: HR, RR, T, ECG rhythm. 7. Monitor for: seizures (diazepam 0.5 mg/kg IV available), worsening arrhythmias, hyperthermia (cool if T exceeds 104 F). 8. Hospitalize for minimum 24 hours with continuous monitoring. 9. Recheck bloodwork (BUN, creatinine) at 24 hours for renal effects. 10. Prognosis: good with early decontamination and monitoring, despite significant dose. Owner informed of treatment plan and cost estimate.

Why These Notes Are Different

These SOAP notes were not written by a human spending 15 minutes per chart. They were generated by VetGeni's AI from voice input in approximately 2 to 3 minutes each. The drug doses, differential diagnoses, and treatment protocols are grounded in Wiley-licensed veterinary references, not generic AI output.

Every clinician who uses VetGeni reviews and approves the generated note before it becomes part of the medical record. The AI does the heavy lifting of structuring and formatting. The clinician provides the clinical judgment. The result is faster, more complete documentation that meets the standard of care.

To see how VetGeni generates SOAP notes from your own clinical narration, visit the SOAP note demo. For a complete guide to veterinary SOAP note documentation, see our complete SOAP notes guide.