How to Write a SOAP Note in Nursing
— With Full Examples
A complete, clinically grounded guide for nursing students and registered nurses — from understanding the Subjective, Objective, Assessment, and Plan framework through writing polished, professional progress notes across every major specialty.
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A SOAP note is a structured clinical documentation format organized into four sequential sections — Subjective, Objective, Assessment, and Plan — that provides a systematic, reproducible method for recording patient encounters, communicating clinical reasoning, and tracking patient progress across shifts, providers, and care settings.
If you’ve ever sat in front of a blank progress note template at the end of a long clinical shift, fingers hovering over the keyboard and brain completely blank, you already know the particular anxiety that SOAP documentation can trigger. You saw the patient. You assessed them. You intervened. But somehow, translating all of that into a clean, logical, chart-worthy note feels like a completely separate — and daunting — skill.
Here’s the thing: SOAP notes aren’t a test of your writing ability. They’re a test of your clinical thinking made visible. The format exists specifically to externalize internal reasoning — to show any provider who opens that chart exactly what you saw, what you thought it meant, and what you did about it. Once that clicks, SOAP documentation stops feeling like paperwork and starts feeling like the professional communication tool it genuinely is.
This guide breaks down every component of the SOAP note in nursing — what goes in each section, what the most common mistakes look like, and what excellent notes actually read like across eight clinical specialties. Whether you’re a nursing student building documentation habits from scratch, a new graduate RN refining your charting, or an NP writing full visit notes in a primary care setting, you’ll find exactly what you need here.
Progress Note
The most common use — documenting patient status, shift events, and responses to interventions in acute care settings.
Admission Note
Comprehensive initial SOAP documentation capturing the full baseline assessment on hospital admission.
Visit Note (Outpatient)
Used by NPs and PAs in clinic settings to document the full patient encounter — history through treatment plan.
Academic Assignment
The format nursing programs use to assess clinical reasoning — typically more detailed than a real-world chart note.
SOAP Notes vs. Nursing Care Plans — What’s the Difference?
These two documentation types are closely related but serve distinct purposes. A nursing care plan is a comprehensive planning document built around NANDA-I nursing diagnoses with goals, interventions, and outcomes. A SOAP note is an encounter-level progress document — typically shorter — that records a specific patient interaction, shift event, or clinical visit. In many programs, students learn both formats in tandem; in practice, SOAP notes are the more frequently written of the two.
The Origin and Clinical Purpose of SOAP Documentation
The SOAP format was developed in the 1960s by Dr. Lawrence Weed at the University of Vermont as part of his Problem-Oriented Medical Record (POMR) system — a revolutionary framework designed to bring logical structure to what was, at the time, chaotic and idiosyncratic clinical charting. According to research published in the Archives of Internal Medicine, Weed’s POMR system and the SOAP note format it spawned represented one of the most significant advances in clinical documentation methodology of the twentieth century.
The medical record must be a scientific document. It must reflect not only what was observed, but the logical chain of reasoning from observation to action — visible to any provider who encounters the patient.
— Dr. Lawrence Weed, originator of the SOAP note formatWhat began as a physician documentation tool rapidly expanded into nursing, nursing practice, physical therapy, social work, and virtually every other clinical discipline because its underlying logic is universal: observe, interpret, act, document. Today, SOAP documentation is embedded in EHR systems across nearly every healthcare setting in the United States, and proficiency in SOAP charting is a competency requirement in accredited nursing programs under both ACEN and CCNE standards.
For nursing students specifically, the SOAP note serves a dual function. It is simultaneously a clinical documentation skill that will follow you through your entire career and a pedagogical tool that forces you to articulate clinical reasoning in writing — which, research in nursing education consistently demonstrates, dramatically accelerates the development of clinical judgment compared to observation or rote skill practice alone.
Why Healthcare Uses SOAP
- Creates a standardized language across disciplines
- Makes clinical reasoning visible and auditable
- Supports care continuity across providers and shifts
- Provides medicolegal protection through documented reasoning
- Reduces communication errors at handoff
- Enables quality improvement and outcome tracking
Why Nursing Students Learn SOAP
- Develops systematic clinical assessment habits
- Trains NCLEX-style priority and delegation thinking
- Bridges classroom knowledge to bedside reasoning
- Satisfies clinical rotation documentation requirements
- Prepares NP students for full autonomous charting
- Builds comfort with EHR documentation systems
The 4 SOAP Components: What Goes Where and Why
Every SOAP note has exactly four sections, and the discipline of placing information in the correct section is what distinguishes a clear, useful note from a muddled one. Understanding the logic behind each section — not just its definition — is what will make this format intuitive.
Subjective — What the Patient Reports
First-person patient voice, history, and symptom narrative
The Subjective section captures everything the patient (or family/caregiver) tells you — information you cannot independently verify through physical examination or diagnostic testing. Think of it as the patient’s testimony about their own experience. The most critical component is the chief complaint (CC), ideally quoted directly in the patient’s own words, followed by the history of present illness (HPI) — the narrative of how this problem developed.
- Chief complaint — the patient’s stated reason for the visit or primary concern, quoted when possible: “Patient states: ‘I’ve had this terrible headache for two days and I can’t keep anything down.'”
- History of present illness (HPI) — onset, location, duration, character, aggravating/relieving factors, radiation, timing, and severity (use the OLD CARTS mnemonic)
- Review of systems (ROS) — patient-reported symptoms across body systems relevant to the complaint
- Past medical/surgical history — chronic conditions, prior surgeries, hospitalizations
- Medications and allergies — current medications with doses, known drug/food allergies and reactions
- Social history — smoking status, alcohol/substance use, occupation, living situation, support system
- Family history — relevant hereditary conditions in first-degree relatives
Objective — What You Measure and Observe
Verifiable, measurable, clinician-generated data
The Objective section contains only information you can independently observe, measure, or verify — vital signs, physical examination findings, laboratory values, imaging results, and standardized assessment scores. This section must be free of interpretation and inference; that work happens in the Assessment section. Every value should be precise and time-stamped where clinically relevant.
- Vital signs — temperature, blood pressure, heart rate, respiratory rate, SpO₂, pain scale score, weight, height, BMI
- Physical examination (PE) — head-to-toe or focused system-by-system findings using inspection, auscultation, percussion, palpation
- Laboratory results — CBC, BMP, CMP, ABGs, urinalysis, culture results, cardiac enzymes, coagulation studies
- Diagnostic imaging and procedures — CXR findings, ECG interpretation, CT/MRI results, echocardiography
- Standardized assessment scores — Braden Scale, Glasgow Coma Scale, MMSE, PHQ-9, AUDIT-C, NIHSS
- Intake and output (I&O) — fluid balance, urine output, drain output
- Current medications administered — what was given, when, at what dose, and patient response where observable
Assessment — Your Clinical Judgment
Interpretation, diagnosis, and clinical reasoning from the data
The Assessment is where your clinical reasoning lives. This is the section most nursing students find most challenging — and most instructors look at most carefully — because it requires synthesizing subjective and objective data into a coherent clinical interpretation. For RN staff nurses, this section reflects the nursing diagnosis and patient status. For NPs and advanced practice nurses writing full visit notes, this section includes the medical diagnosis (or differential diagnoses), acuity, and complexity.
- Nursing diagnosis (RN) — NANDA-I formatted diagnosis in PES format: Problem r/t Etiology AEB Signs/Symptoms
- Medical diagnosis or differential (NP/APRN) — primary diagnosis with ICD-10 code, differential diagnoses with reasoning
- Acuity and stability — is the patient stable, improving, declining, or at risk for deterioration?
- Priority problems — which issue is most urgent and why? Apply ABCs and Maslow’s hierarchy
- Clinical reasoning narrative — brief explanation connecting S and O data to the assessment conclusion
- Response to current treatment — is the current plan working? Any unexpected responses?
Plan — What Happens Next
Interventions, orders, education, referrals, and follow-up
The Plan section documents every action taken or ordered in response to the assessment. It should be specific, actionable, and directly traceable back to the problems identified in the Assessment. A vague plan — “continue to monitor” without parameters — is a documentation red flag in both academic and clinical settings. Every Plan entry should answer: Who will do what, with what, by when, and how will success be measured?
- Nursing interventions — independent actions: repositioning schedule, patient education, fall precautions, skin care, breathing exercises
- Medications administered or ordered — drug name, dose, route, frequency; PRN parameters and when to escalate
- Diagnostic orders — labs, imaging, procedures ordered or pending
- Referrals and consultations — PT, OT, dietitian, wound care, social work, specialist
- Patient and family education — what was taught, method used, teach-back result, patient’s verbalized understanding
- Safety and precautions — fall precautions, DVT prophylaxis, aspiration precautions, isolation orders
- Follow-up and evaluation parameters — when to reassess, threshold values for escalation, anticipated outcomes
The Single Most Useful SOAP Writing Rule
Before writing each sentence, ask yourself: “Is this what someone told me, or what I measured myself?” If someone told you → Subjective. If you measured or observed it → Objective. If it’s your interpretation of those two data sets → Assessment. If it’s an action → Plan. Keeping this question front of mind eliminates the vast majority of information misplacement errors that cost students points.
How to Write a SOAP Note: A Step-by-Step Process
Writing an excellent SOAP note is a sequential process. Most students who struggle with the format are trying to write and think simultaneously rather than following a deliberate workflow. The steps below separate the thinking from the writing so each phase can be done well.
Gather and Organize Your Raw Data Before You Write Anything
Conduct or review the full patient assessment before opening the documentation screen. Pull vital signs, review the MAR, check recent labs, and speak with the patient. Use a structured brain sheet or assessment tool to organize your findings by type — patient-reported (subjective) and clinician-measured (objective). Trying to write the note while simultaneously gathering information almost always results in disorganized, incomplete documentation. Separate the data collection phase from the writing phase.
Write the Subjective Section Using the Patient’s Own Language
Begin with a direct quote of the chief complaint where possible, then expand into the HPI. Use the OLD CARTS framework (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) to ensure completeness. When documenting pain or symptoms, record the patient’s own words rather than paraphrasing — “patient states the pain feels ‘like someone is squeezing my chest'” is more clinically useful than “patient reports chest pain.” Include relevant PMH, current medications, allergies, and social history at the level of detail appropriate to the clinical context.
Write the Objective Section Using Precise, Time-Stamped Values
Document all measurable findings in the conventional head-to-toe or system-by-system order used at your institution. Vital signs should always include all parameters with the time of measurement. Physical exam findings should be specific — “breath sounds diminished in bilateral bases with expiratory wheezes” is objective; “the patient sounds wheezy” is neither specific enough nor professional. Include all relevant labs with reference ranges noted for abnormal values. Every number should stand alone without interpretation — the interpretation belongs in Assessment.
Write the Assessment by Synthesizing S and O Into a Clinical Judgment
This is where you earn your clinical credibility. Start with the primary nursing or medical diagnosis and briefly explain the reasoning: what specific S and O data points support this conclusion? Then address priority ranking — which problem is most urgent and why? For nurses, frame this in terms of NANDA-I diagnostic labels with PES format. For NPs, include your primary diagnosis, relevant differential diagnoses you considered and ruled out, and your rationale. This section should never just restate the S and O — it must add interpretive value.
Write the Plan With Specific, Measurable, Time-Bound Actions
Address every problem identified in the Assessment with at least one specific action. Group actions logically: medications, monitoring parameters, nursing interventions, education, referrals, and follow-up. Include the rationale for each significant intervention when writing academic SOAP notes — instructors look for evidence of reasoning behind the plan, not just a list of tasks. Specify evaluation parameters: when you will reassess, what values will trigger escalation, and what outcomes define success for this encounter.
Review for Completeness, Accuracy, and Professional Language
Before finalizing any SOAP note, read through each section and verify: Is all subjective information sourced from the patient or caregiver? Are all objective values specific and accurately recorded? Does the assessment logically follow from the data? Does the plan address every problem in the assessment? Check for prohibited phrases (see the Do’s and Don’ts section), spelling errors, and any accidental inclusion of information in the wrong section. In EHR documentation, ensure the timestamp is accurate before signing.
The OLD CARTS Framework for the Subjective HPI
| Letter | Element | Sample Questions to Ask | Documentation Example |
|---|---|---|---|
| O | Onset | When did it start? What were you doing when it began? | “Pain began suddenly at 0300 while patient was at rest” |
| L | Location / Radiation | Where exactly is it? Does it travel anywhere? | “Substernal pressure radiating to the left jaw and arm” |
| D | Duration | How long does it last? Is it constant or intermittent? | “Constant since onset; has not resolved” |
| C | Character | How would you describe it? Sharp, dull, burning, pressure? | “Patient describes ‘crushing, heavy pressure’ — not sharp” |
| A | Aggravating factors | What makes it worse? | “Worsens with exertion; not positional” |
| R | Relieving factors | What makes it better? | “Partial relief with sublingual nitroglycerin x1” |
| T | Timing | First time? How often does it happen? | “Third episode in past two weeks; similar but more severe” |
| S | Severity | On a scale of 0–10, how bad is it? | “Patient rates pain 9/10 at onset; currently 7/10” |
Complete Nursing SOAP Note Examples Across Clinical Specialties
The following eight examples demonstrate complete, professionally written SOAP notes across major nursing specialties. Each note is written at the level of detail appropriate for an academic nursing assignment — which typically requires more explicit reasoning than a routine EHR chart note. Read each as a model of thinking made visible on paper, not as a template to copy verbatim, since your note must always reflect your specific patient’s individual data.
Example 1: Acute Chest Pain — Emergency Department
ED / CardiacHPI: Mr. T.K., 58-year-old male, presents to the ED via EMS with a 2-hour history of acute substernal chest pressure rated 9/10 on NRS, radiating to the left arm and jaw. Patient describes onset as sudden, occurring while seated watching television. Denies positional changes, pleuritic quality, or reproduction with palpation. Reports associated diaphoresis, nausea, and shortness of breath. States he took one sublingual nitroglycerin (his wife’s) en route, with partial relief to 7/10. Third episode in two weeks; prior two episodes were less severe and self-resolved. PMH: Hypertension (HTN), hyperlipidemia (HLD), Type 2 Diabetes Mellitus (T2DM), 30-pack-year smoking history (quit 5 years ago). Medications: Lisinopril 10 mg daily, atorvastatin 40 mg nightly, metformin 1000 mg BID, aspirin 81 mg daily. Allergies: Penicillin (rash). Family history: Father deceased at 61 — MI. Brother with CABG at 55.
General: Alert and oriented ×4, anxious-appearing male in moderate distress, diaphoretic, skin pale and clammy.
Cardiovascular: Regular rate and rhythm (RRR), no murmurs, rubs, or gallops on auscultation. Peripheral pulses 2+ bilaterally. No JVD.
Respiratory: Mild accessory muscle use. Breath sounds clear to auscultation bilaterally; no crackles or wheezes.
ECG (14:24): 1.5–2 mm ST elevation in leads II, III, aVF; reciprocal ST depression in I and aVL. Normal sinus rhythm at 102 bpm.
Labs: Troponin I 0.42 ng/mL (ref: <0.04 ng/mL — critically elevated); BNP 78 pg/mL; CBC WNL; BMP: glucose 214 mg/dL, Cr 1.0 mg/dL, K+ 4.1 mEq/L; PT/INR 1.1.
Priority Nursing Diagnoses:
1. Decreased Cardiac Output r/t altered contractility secondary to myocardial ischemia AEB HR 102 bpm, BP 158/94, SpO₂ 94%, pallor, diaphoresis
2. Acute Pain r/t myocardial ischemia AEB pain rated 7/10, diaphoresis, guarded positioning
3. Anxiety r/t acute life-threatening event AEB anxious affect, tachycardia, patient verbalization of fear
Acuity: Critical — immediate intervention required. Time-to-balloon goal is <90 minutes from first medical contact.
- Activate cardiac catheterization lab immediately — STEMI alert called at 14:26; cardiology on-call notified
- Administer aspirin 325 mg PO non-enteric coated loading dose per ACS protocol (in addition to home dose)
- Administer ticagrelor 180 mg PO loading dose per order — dual antiplatelet therapy for STEMI per ACC/AHA guidelines
- Establish 2 large-bore IV access (18G bilateral antecubital); initiate 0.9% NS at KVO rate
- Apply supplemental O₂ via nasal cannula at 2L/min — titrate to SpO₂ ≥ 95%
- Initiate continuous cardiac monitoring; obtain 12-lead ECG q30 min until cath lab transfer
- Keep NPO — preparation for emergent PCI
- Reassure patient and family regarding plan; explain procedure in simple terms — reduce anxiety, support informed consent
- Transfer to cardiac cath lab when team ready — document time of departure
Example 2: Postpartum Shift Assessment — Labor & Delivery / Mother-Baby
OB / PostpartumHPI: Ms. A.M., 28-year-old G2P2, is 14 hours postpartum following a spontaneous vaginal delivery with 2nd-degree perineal laceration requiring repair. Delivery was uncomplicated; estimated blood loss 350 mL. Reports perineal pain rated 4/10 at rest, 7/10 with ambulation; managed with ibuprofen and ice pack. No complaints of headache, visual changes, or right upper quadrant pain. Reports voiding spontaneously — last void approximately 2 hours ago. Reports fatigue and mild nipple soreness. Expresses desire to breastfeed exclusively. Denies fever, chills, or foul-smelling lochia.
Fundus: Firm, midline, at umbilicus — appropriate for 14 hours postpartum.
Lochia: Rubra — moderate flow, no clots, no foul odor. Peripad saturated over 4-hour period — within normal limits.
Perineum: 2nd-degree laceration repair intact; mild edema and ecchymosis present; no separation, drainage, or signs of infection. Ice pack in place.
Breasts: Soft, no engorgement noted; nipples intact bilaterally, no cracking or blistering. Colostrum expressed with gentle compression bilaterally.
Extremities: 1+ pitting edema bilateral lower extremities; no calf tenderness, redness, or warmth. Homans’ sign not elicited.
Infant latch observed: Infant not achieving sustained latch; tongue appears to remain elevated with limited extension noted on brief assessment.
1. Acute Pain r/t perineal laceration and surgical repair AEB pain rated 4/10 at rest and 7/10 with ambulation, perineal edema and ecchymosis observed
2. Ineffective Breastfeeding r/t inadequate infant latch and possible infant ankyloglossia AEB infant unable to sustain latch, maternal report of repeated latch-and-pull-off behavior, no audible swallowing during observed feeding attempt
3. Risk for Infection r/t perineal tissue disruption and laceration repair — no current defining characteristics; prophylactic interventions indicated
Patient is clinically stable. Vital signs within postpartum normal limits. Postpartum hemorrhage risk currently low — fundus firm, lochia appropriate.
- Administer ibuprofen 600 mg PO q6h scheduled (not PRN) for perineal pain management; reassess in 30–60 min
- Continue ice pack application 20 min on / 20 min off for first 24 hours — reduces edema and acute perineal pain
- Consult lactation nurse specialist for breastfeeding evaluation — ankyloglossia (tongue-tie) assessment and individualized latch coaching
- Teach and demonstrate football hold and cross-cradle hold as alternative positioning — reduces nipple friction during latch
- Demonstrate proper perineal care with peri bottle after each void — reduces infection risk and patient discomfort
- Reinforce peripad change frequency and lochia monitoring — instruct on signs of abnormal bleeding to report immediately
- Reassess fundal firmness and lochia volume in 4 hours; reassess pain score in 1 hour post-medication
Example 3: Pediatric Respiratory Distress — Inpatient (Age 4)
Pediatrics / RespiratoryHPI (parent-reported): L.K., a 4-year-old male with a known history of asthma, presented to the inpatient unit following ED evaluation for acute asthma exacerbation not responding to bronchodilator therapy in the outpatient setting. Mother reports symptoms began yesterday evening after playing outdoors during high pollen/mold count day. Albuterol MDI used 6 times over 12 hours with decreasing effectiveness. Denies fever, recent viral illness, or new exposures. No vomiting. Last ate and drank at breakfast — approximately 5 hours ago. PMH: Asthma (mild persistent), seasonal allergic rhinitis. Medications: Fluticasone propionate 44 mcg 2 puffs BID (controller), albuterol MDI (rescue — used PRN). Allergies: Amoxicillin (urticaria). No family tobacco smoke exposure per mother.
General: Alert, crying and anxious, in obvious respiratory distress. Mild perioral cyanosis noted on arrival; resolving with O₂.
Respiratory: Moderate subcostal and intercostal retractions bilaterally. Nasal flaring present. Breath sounds diminished bilaterally with prominent expiratory wheeze in all lung fields. Accessory muscle use (sternocleidomastoid) present. Prolonged expiratory phase.
PRAM Score: 9/12 — Severe asthma exacerbation.
Peak Flow: Unable to perform reliably (age-appropriate limitation).
ABG (venous, per ED): pH 7.32, pCO₂ 48 mmHg, pO₂ 58 mmHg — early respiratory acidosis; indicates tiring respiratory effort.
1. Ineffective Airway Clearance r/t bronchospasm and mucus production AEB SpO₂ 89% RA, RR 38, bilateral expiratory wheezes, subcostal/intercostal retractions, PRAM score 9/12
2. Impaired Gas Exchange r/t air trapping and ventilation-perfusion mismatch AEB venous pH 7.32, pCO₂ 48 mmHg, perioral cyanosis on presentation
3. Anxiety r/t respiratory distress and unfamiliar environment AEB crying, anxious affect, increased work of breathing potentiated by distress
Acuity: High. Severe asthma exacerbation with early ventilatory fatigue; risk for respiratory failure if no response to escalated bronchodilator therapy. ICU consultation pending.
- Maintain supplemental O₂ via nasal cannula 2L/min — titrate to SpO₂ ≥ 95%; escalate to high-flow if SpO₂ does not improve
- Administer albuterol 2.5 mg via nebulizer q20 min × 3 doses per order; assess response after each treatment
- Administer ipratropium bromide 0.5 mg nebulized combined with first three albuterol treatments — additive bronchodilation per GINA guidelines
- Administer oral prednisolone 1 mg/kg (max 40 mg) per order — systemic corticosteroids reduce airway inflammation and reduce hospitalization duration
- Position patient in high Fowler’s or allow patient to assume position of comfort — optimizes diaphragmatic excursion
- Allow mother to remain at bedside for comfort — parental presence reduces anxiety and work of breathing in pediatric patients
- Continuous SpO₂ and cardiac monitoring; assess PRAM score q1h; reassess breath sounds after each nebulization
- Notify provider immediately if SpO₂ <92% on supplemental O₂, RR >45, pCO₂ rising on serial VBG, or patient appears exhausted
Example 4: Mental Health Assessment — Inpatient Psychiatric Unit
Psychiatric / Mental HealthHPI: Ms. D.N., 34-year-old female with known Bipolar I Disorder, admitted 36 hours ago following a 72-hour period of significantly decreased sleep (2–3 hrs total), pressured and rapid speech, impulsive financial decisions (reported spending $6,400 on online purchases in 48 hrs), and reports from family of grandiose statements and hypersexual behavior — representing a marked departure from her baseline. Denies suicidal or homicidal ideation. Denies auditory or visual hallucinations. Denies substance use. Acknowledges she feels “better than ever” and sees no reason for hospitalization. Medications on admission: Lithium carbonate 900 mg BID (patient self-reportedly stopped 3 weeks ago — “I felt fine”), quetiapine 200 mg qHS. Allergies: Valproate (hepatotoxicity — prior).
Mental Status Exam: Appearance — dressed in bright mismatched colors, hair disheveled; hygiene adequate. Attitude — cooperative but intermittently redirectable. Behavior — psychomotor agitation, pacing observed prior to interview. Speech — pressured, rapid, loud, tangential. Thought process — flight of ideas, loose associations, easily distracted. Thought content — grandiose ideation (“I’m starting three companies this week”), no delusions, no suicidal/homicidal ideation. Perceptual disturbances — denies; none observed. Mood (stated) — “incredible, on top of the world.” Affect — expansive, incongruent with situation. Cognition — alert and oriented ×4; concentration markedly impaired. Insight — poor; does not acknowledge illness. Judgment — grossly impaired.
YMRS (Young Mania Rating Scale): 38/60 — Severe mania.
Lithium level (AM draw): 0.2 mEq/L (therapeutic target: 0.8–1.2 mEq/L) — subtherapeutic, consistent with reported nonadherence.
1. Risk for Injury (Self/Others) r/t impaired judgment, grandiosity, and psychomotor agitation secondary to manic episode — no current defining characteristics but high acuity given YMRS 38 and absent therapeutic lithium level
2. Disturbed Thought Processes r/t acute manic episode and medication nonadherence AEB flight of ideas, grandiose ideation, poor insight, YMRS 38/60
3. Sleep Deprivation r/t hyperarousal secondary to mania AEB patient-reported 2–3 hours total sleep over past 72 hours, psychomotor agitation, impaired concentration
4. Ineffective Health Management r/t insufficient knowledge of consequences of medication nonadherence AEB voluntary discontinuation of lithium and resulting subtherapeutic level (0.2 mEq/L)
Acuity: High. Severe manic episode with impaired judgment poses safety risk. Medication stabilization is the immediate clinical priority.
- Administer lithium carbonate 900 mg BID per order; monitor lithium level in 5 days (goal 0.8–1.0 mEq/L for acute mania)
- Administer quetiapine 200 mg qHS per order — antipsychotic augmentation for manic episode and sleep promotion
- Maintain 1:1 nurse-patient safety check every 15 minutes per unit protocol during acute phase — monitor for escalating agitation or impulsive behavior
- Maintain low-stimulation environment — limit visitors, reduce noise, dim lighting; overstimulation exacerbates mania
- Offer high-calorie snacks and fluids throughout the day — manic patients commonly do not pause to eat or drink adequately
- Use brief, calm, non-confrontational communication; avoid arguing with grandiose statements — therapeutic limit-setting without power struggles
- Provide psychoeducation about lithium adherence and early warning signs of mania — brief sessions only; receptiveness will improve as mania resolves
- Reassess YMRS daily; reassess sleep duration each shift; notify provider if agitation escalates or patient refuses medications
Example 5: Diabetic Foot Ulcer — Outpatient Wound Care Clinic
Wound Care / EndocrineHPI: Mr. O.B., 66-year-old male with a 22-year history of T2DM and peripheral neuropathy, presents to the outpatient wound care clinic for management of a right plantar foot ulcer, present for 6 weeks. Patient denies pain at the wound site (consistent with peripheral neuropathy). Reports poor glycemic control this week — fasting blood glucoses 180–260 mg/dL. Reports wearing prescribed diabetic footwear inconsistently — “it’s uncomfortable.” Denies fever, chills, or red streaking from wound. Wife present and participates in discussion. PMH: T2DM, HTN, CKD Stage 3a, peripheral arterial disease (PAD), peripheral neuropathy. HbA1c most recent (3 months ago): 9.8%. Medications: Metformin 1000 mg BID, glipizide 10 mg daily, lisinopril 20 mg daily, aspirin 81 mg daily. Allergies: Sulfa drugs (rash).
Wound Assessment (Right Plantar Foot, 1st Metatarsal Head):
— Size: 3.2 cm × 2.8 cm × 0.4 cm depth (increased from 2.6 × 2.1 cm at last visit 2 weeks ago)
— Wound bed: 60% yellow slough, 40% pale granulation tissue — no healthy bright-red granulation
— Periwound: Erythema 1.5 cm margin circumferentially; mild warmth; no induration; no crepitus
— Exudate: Moderate serosanguineous — no purulence
— Odor: Mild
— Wagner Grade 2 (deep ulcer to tendon/capsule; no abscess)
Vascular: Dorsalis pedis pulse 1+ right, 2+ left. Ankle-Brachial Index (ABI) right: 0.72 — mild-to-moderate peripheral arterial disease.
Neurological: 10-g monofilament — sensation absent at 6/10 plantar test sites bilateral feet.
Blood glucose (point-of-care): 214 mg/dL.
1. Impaired Tissue Integrity r/t peripheral neuropathy, reduced tissue perfusion (ABI 0.72), and uncontrolled hyperglycemia (POC BG 214, HbA1c 9.8%) AEB Wagner Grade 2 plantar ulcer with wound enlargement from 2.6 cm to 3.2 cm over 2 weeks, 60% slough, periwound erythema
2. Ineffective Peripheral Tissue Perfusion r/t PAD and arterial insufficiency AEB ABI 0.72, dorsalis pedis 1+ right, pale wound granulation
3. Risk for Infection r/t wound depth, periwound erythema, impaired immune function secondary to hyperglycemia
4. Ineffective Self-Health Management r/t inconsistent adherence to offloading protocol AEB patient report of inconsistent therapeutic footwear use and worsening wound size
Clinical Concern: Wound enlargement despite 6 weeks of outpatient management combined with compromised perfusion (ABI 0.72) and hyperglycemia raises risk for deep infection and osteomyelitis. Vascular surgery and endocrinology referrals warranted.
- Débride wound — sharp débridement of slough tissue to expose viable wound bed; apply silver-containing dressing (e.g., Mepilex Ag) for antimicrobial management of periwound erythema
- Obtain wound swab culture — guide antibiotic selection if infection confirmed
- Refer to vascular surgery — ABI 0.72 with non-healing wound: revascularization assessment warranted per wound care protocol
- Refer to endocrinology for glycemic optimization — HbA1c 9.8% is a major wound healing barrier; medication adjustment likely needed
- Educate patient and wife on strict total contact casting / offloading compliance — demonstrated the direct relationship between pressure relief and wound closure; involve wife as accountability partner
- Order plain radiographs of right foot — rule out osteomyelitis given wound depth and duration
- Reassess wound at 1-week follow-up; if no improvement or signs of systemic infection, inpatient admission for IV antibiotics and surgical evaluation
External Evidence Sources for Your SOAP Note Rationales
For evidence-based rationales in your assessment and plan sections, always trace back to primary sources. For nursing documentation standards, consult the American Nurses Association (nursingworld.org), which maintains the official Nursing: Scope and Standards of Practice that governs professional documentation obligations. For clinical intervention evidence, use PubMed Central (ncbi.nlm.nih.gov/pmc) to access peer-reviewed nursing and medical literature. Both are freely accessible and represent the gold standard in academic nursing citation.
Example 6: Post-Stroke Shift Note — Neurological Unit
Neurology / StrokeReport from night shift nurse and patient chart: Mr. C.O., 71-year-old male, Day 3 post-ischemic stroke (left MCA territory). Presented with sudden onset right-sided hemiparesis, expressive aphasia, and right facial droop. Received tPA within 3.5-hour window on Day 1. Patient reports persistent right arm weakness and expressive aphasia — improved from Day 1 but not back to baseline. Reports difficulty swallowing. Denies headache, seizure, or chest pain. Expresses fear and frustration about recovery — “I don’t know… if I’ll talk normal again.” Wife at bedside, verbalizes anxiety about discharge planning. PMH: HTN, atrial fibrillation (AF), T2DM. Medications: Aspirin 325 mg daily (new post-stroke), apixaban 5 mg BID (held for 48 hrs post-tPA; restarted today per neurology order), lisinopril 10 mg daily, metformin 500 mg BID. Allergies: NKDA.
Neurological: Alert, oriented ×4. Expressive aphasia — effortful, telegraphic speech; comprehension intact as demonstrated by ability to follow two-step commands accurately. Right facial droop present (mild, improved from Day 1). Right upper extremity (RUE): strength 2/5 throughout, unable to overcome gravity; right lower extremity (RLE): 3+/5, able to ambulate short distances with PT assist and hemi-walker. Left side strength 5/5. No Babinski. NIHSS today: 8 (Day 1 was 14) — improvement noted.
Swallow: Bedside swallow screen performed — patient coughed on thin liquids ×2; passed on nectar-thick consistency. SLP formal evaluation ordered.
Skin: Intact throughout. Sacrum and heels inspected — no erythema or breakdown. Braden Scale: 16 (mild risk).
Cardiac: Irregularly irregular rhythm consistent with known AF; apical HR 82 bpm. No S3/S4.
1. Impaired Physical Mobility r/t neuromuscular deficit secondary to left MCA ischemic stroke AEB RUE strength 2/5, RLE 3+/5, NIHSS 8, requires PT assistance for ambulation
2. Impaired Verbal Communication r/t expressive aphasia secondary to Broca’s area involvement AEB effortful telegraphic speech, difficulty word-finding, patient-expressed frustration
3. Risk for Aspiration r/t dysphagia evidenced by coughing on thin liquids during bedside screen — formal SLP evaluation pending
4. Anxiety r/t uncertainty about functional recovery AEB patient stating fear about speech recovery, wife’s expressed distress
Trajectory: Improving — NIHSS improvement from 14 to 8 over 3 days is encouraging. Full functional outcome prognosis remains guarded at this stage.
- Maintain nectar-thick liquids and pureed diet per bedside screen results until SLP formal evaluation complete — aspiration prevention
- SLP consultation today for formal dysphagia evaluation and safe swallow diet recommendation
- PT/OT twice daily — gait training, RUE mobilization, ADL retraining per inpatient stroke rehabilitation protocol
- Use augmentative communication strategies: picture board, yes/no questions, written prompts — reduces patient frustration, supports therapeutic communication
- Maintain BP target 140–160 mmHg systolic per neurology order — avoid aggressive BP lowering in acute ischemic stroke recovery period
- Reposition q2h; assess skin at each repositioning — Braden 16 indicates mild pressure injury risk; proactive prevention
- Initiate stroke support group referral and social work consult for patient and family discharge planning and psychosocial support
- Reassess NIHSS, neurological baseline, and swallow status each shift
SOAPIE, SOAPER, DAR, and Other Nursing Note Formats
The standard SOAP format is not the only clinical documentation framework in use. Depending on your program, institution, or specialty, you may encounter extended or alternative formats. Understanding how these relate to — and differ from — the core SOAP structure will prevent confusion during clinical placements.
| Format | Full Acronym | Additional Sections | Common Use Setting |
|---|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | — | Primary care, acute care, most outpatient settings |
| SOAPIE | + Intervention, Evaluation | I — Nursing actions taken; E — Patient response to those actions | Academic nursing assignments, some acute care settings |
| SOAPIER | + Intervention, Evaluation, Revision | R — Updated plan based on evaluation findings | Academic programs requiring care plan integration |
| DAR | Data, Action, Response | Focus: Action and patient response, less narrative | Long-term care, skilled nursing facilities, some psychiatric settings |
| APIE | Assessment, Plan, Intervention, Evaluation | No separate S/O split; combined assessment | Some UK nursing systems and midwifery documentation |
| BIRP | Behavior, Intervention, Response, Plan | Behavior-focused format for behavioral observations | Mental health, substance use treatment, behavioral therapy |
Academic vs. Real-World SOAP Notes: What’s Different?
Academic SOAP notes — the kind you write for nursing school assignments — are typically longer, more explicit in reasoning, and more detailed in rationale than real-world EHR documentation. In clinical practice, nurses use standardized EHR fields, drop-down menus, and institution-specific templates that pre-populate much of the documentation structure. Academic notes ask you to write it all out longhand precisely because making the reasoning explicit is how clinical thinking is assessed and developed. Don’t be surprised or alarmed when your clinical preceptor’s chart notes look significantly briefer than what your instructor requires on paper.
The SOAPIE Format: When and How to Use It
Many nursing programs use SOAPIE rather than standard SOAP because the added Intervention and Evaluation sections align the note format more directly with the nursing process (ADPIE). In SOAPIE, the I section documents the specific nursing interventions carried out (distinct from the Plan, which documents what was ordered or planned), and the E section documents the patient’s measurable response to those interventions. If you are unsure which format your program requires, always check the assignment rubric — the distinction between SOAP and SOAPIE is one of the most common sources of lost points on nursing documentation assignments.
O — Objective: BP 158/94, HR 102, SpO₂ 94%, ST elevation leads II/III/aVF, Troponin 0.42…
A — Assessment: Acute Inferior STEMI; Decreased Cardiac Output r/t myocardial ischemia AEB…
P — Plan: STEMI alert activated; aspirin 325 mg PO; ticagrelor 180 mg PO; O₂ 2L NC; IV access × 2…
I — Intervention: Aspirin administered 14:29; ticagrelor administered 14:31; O₂ applied 14:26 (SpO₂ ↑ 97%); cath lab transfer 14:45…
E — Evaluation: SpO₂ improved to 97% on 2L O₂; pain decreased from 7/10 to 5/10 following medications; patient transferred to cath lab 14:45 — time-to-door-balloon goal met.
SOAP Note Do’s and Don’ts: Professional Documentation Standards
Clinical documentation is a legal record. Every entry in a patient’s chart — including SOAP notes written on paper for nursing school — reflects your professional standards, your attention to detail, and your clinical reasoning ability. The following do’s and don’ts represent the difference between documentation that protects the patient, the nurse, and the institution, and documentation that creates risk and communicates incompetence.
Phrases That Should Never Appear in a Professional SOAP Note
- “Patient appears to be…” — document what you observe, not what you assume
- “Appears normal” — state specifically what you assessed and found
- “Patient is a good historian” — irrelevant; document the history, not the quality of its delivery
- “No complaints at this time” — vague; specify what was assessed and what was and wasn’t reported
- “Nurse will continue to monitor” — what specifically? For what? With what parameters for escalation?
- “Patient is stable” alone without supporting data — meaningless without the vital signs and assessment that define stability
- Any abbreviation not on your institution’s approved list — TJC prohibits certain abbreviations (e.g., “QD,” “U” for units) due to documented error rates
How SOAP Notes Adapt Across Clinical Specialties
While the four-section structure of a SOAP note is universal, the emphasis, depth, and content within each section varies significantly depending on clinical specialty. A psychiatric SOAP note looks markedly different from a surgical one, even though both follow the same S-O-A-P skeleton. Understanding these specialty-specific adaptations prepares you for the diversity of clinical placements in your nursing education and career.
| Specialty | Key Subjective Focus | Key Objective Focus | Assessment Emphasis | Plan Emphasis |
|---|---|---|---|---|
| Medical-Surgical | Pain, functional changes, bowel/bladder, appetite | Vital signs, wound status, I&O, lab trends | NANDA diagnoses; stability vs. deterioration | Medications, activity progression, discharge teaching |
| Psychiatric/Mental Health | Mood, thoughts, sleep, behavior changes, safety | Mental Status Exam (MSE), validated scales (PHQ-9, YMRS, AUDIT-C) | Safety risk stratification; diagnostic impression | Therapeutic milieu, medication adherence, de-escalation |
| Pediatrics | Parent-reported HPI; developmental history; immunizations | Weight-based vitals; growth percentile; age-appropriate neuro exam | Age-referenced norms; parental insight and capacity | Weight-based dosing; caregiver education; follow-up schedule |
| Obstetrics / Postpartum | Lochia, pain, breastfeeding, emotional status, voiding | Fundal assessment, perineal exam, infant latch observation, Homan’s | Normal vs. complicated postpartum; hemorrhage risk | Pain management, breastfeeding support, discharge education |
| Critical Care (ICU) | Limited subjective (intubated patients); family-reported changes | Continuous hemodynamic monitoring, ventilator parameters, vasopressor doses, organ function labs | Organ system-by-system analysis; trajectory (improving/worsening) | Bundles (VAP, CLABSI prevention), daily goals, family communication |
| Geriatrics / Long-Term Care | Functional decline, fall history, confusion, nutrition, pain | Cognitive screening (MMSE, MoCA), fall risk tools, Braden Scale, weight trends | New vs. chronic problems; functional status trajectory; delirium vs. dementia | Fall prevention, skin care, advance care planning, family goals of care |
SOAP Notes in Advanced Practice Nursing (NP / APRN)
Nurse practitioners and other advanced practice registered nurses (APRNs) write SOAP notes that extend significantly beyond the scope of staff RN documentation. In the NP context, the Assessment section includes medical diagnoses with ICD-10 codes, a formal differential diagnosis list with reasoning for ruling in or out each possibility, and a full problem list that may address multiple chronic conditions. The Plan section includes prescription orders, referral letters, diagnostic test orders, and detailed patient education with return precautions. NP students at the MSN and DNP levels are held to physician-comparable documentation standards in their academic SOAP notes.
Common SOAP Note Errors and How to Fix Them
Most errors in nursing SOAP notes fall into predictable patterns. The table below identifies the errors instructors and clinical supervisors flag most frequently — along with the precise correction for each. Reviewing this list before submitting any SOAP note assignment will eliminate the most avoidable point losses.
| ❌ Common Error | Why It’s a Problem | ✓ The Fix |
|---|---|---|
| Mixing subjective and objective data in the wrong sections | Undermines the logical structure of the note; makes clinical reasoning impossible to follow | Apply the rule: did someone report it to me (S) or did I measure/observe it independently (O)? Never place patient-reported symptoms in the Objective section |
| Using a medical diagnosis in the Assessment instead of a nursing diagnosis | Nurses document human responses to health problems, not medical disease labels; goes beyond nursing scope for staff RNs | Use NANDA-I PES format: Problem r/t Etiology AEB Defining Characteristics. Exception: NPs write medical diagnoses in assessment by scope |
| Assessment contains only a restatement of S and O | Assessment must add interpretive value — connecting data to a clinical judgment. Restating data is not assessment | Ask: “What does this data mean about this patient’s health status?” Then write that interpretation with specific data reference |
| Plan items are not linked to problems in the Assessment | Every Plan item must be traceable to a specific problem identified in Assessment. Orphaned interventions signal incomplete reasoning | Cross-check: every nursing diagnosis/problem in Assessment should have at least one corresponding Plan action |
| Vital signs listed without context or clinical interpretation | Abnormal values must be clearly identified; normal-range values need contextual notation. A list of numbers without flagging is incomplete | Note which values are outside reference range; carry abnormal values into the Assessment section as supporting data |
| Missing evaluation parameters or follow-up timelines in the Plan | Without “when to reassess” and “what triggers escalation,” the Plan is not actionable for the next provider | End each Plan section with: (1) when you will reassess, (2) specific threshold values that trigger escalation or provider notification |
| Risk diagnoses written with defining characteristics | Risk diagnoses are potential problems — by definition, defining characteristics (signs/symptoms) are not yet present | Risk diagnoses use only: “Risk for [Label] r/t [Risk Factors]” — remove the “AEB” clause entirely |
| Unprofessional language, abbreviations, or editorial commentary | Chart notes are legal documents; language like “patient was difficult” or unapproved abbreviations create liability and unprofessionalism | Use clinical, neutral, objective language. “Patient declined repositioning at 14:00 and stated ‘I’m not moving'” is clinical; “patient was uncooperative” is editorial |
Pre-Submission SOAP Note Checklist
- Every item in the Subjective section was reported by the patient, family, or referring provider — not observed by me
- Every item in the Objective section is a specific, measurable value or finding I obtained independently
- The Assessment section contains a clinical interpretation — not just a restatement of S and O data
- Each nursing diagnosis is in PES format (for actual) or risk-factor-only format (for risk diagnoses)
- Every problem in the Assessment has at least one corresponding Plan action
- The Plan specifies who, what, when, and how success will be measured for each intervention
- No unprofessional language, unapproved abbreviations, or editorial commentary present
- SOAPIE: Intervention section documents actions actually taken (past tense); Evaluation documents patient’s observed response
FAQs: Your Burning Questions About SOAP Notes Answered
Bringing It All Together: SOAP Notes as Clinical Thinking on Paper
A well-written SOAP note is not a documentation chore. It is the most direct window anyone has into the quality of your clinical thinking — and in nursing, clinical thinking is the entire profession. When a charge nurse, a physician, an NP, or an incoming shift nurse opens your note, they should be able to understand in seconds what was happening with this patient, what you concluded from the data, and exactly what you did about it.
The structure — Subjective, Objective, Assessment, Plan — is the scaffolding. But the intelligence inside it comes from you: your thoroughness in gathering data, your honesty in reporting it accurately, your rigor in interpreting it clearly, and your discipline in planning specifically enough that the next clinician can act on what you documented. That chain of quality — data, reasoning, action, documentation — is what safe, excellent nursing care looks like made visible.
Start every note by separating your data into what the patient told you and what you measured independently. Keep the Assessment section interpretive, not descriptive. Make the Plan specific enough that any competent nurse reading it knows exactly what to do next. And always, always evaluate — document how the patient responded to the care you provided.
For additional expert support across your nursing coursework — from SOAP notes to nursing care plans, SBAR reports, PICOT questions, and evidence-based practice papers — the experienced nursing writers at Smart Academic Writing are here to help you succeed at every level of your clinical education.