Nursing SOAP Note Template

Copy this block into your clinical log and fill it in from top to bottom. Each heading is the exact wording most nursing and NP programs expect.

SUBJECTIVE
Chief complaint (patient's own words):
HPI (OLDCARTS): Onset / Location / Duration / Character /
  Aggravating & alleviating / Radiation / Timing / Severity
Pertinent positives:
Pertinent negatives (relevant ROS only):
PMH / PSH:
Medications + allergies:
Family / social history (as relevant):

OBJECTIVE
Vitals: T / HR / RR / BP / SpO2 / pain / weight / BMI
General appearance:
Focused physical exam by system:
Labs, imaging, point-of-care results:
Validated screening scores (e.g. PHQ-9, GAD-7, CAM, Braden):

ASSESSMENT
Primary diagnosis with ICD-10 and the data supporting it:
Differential diagnoses (2-3) with why each is less likely:
Nursing diagnoses (NANDA-I, PES format) if required:

PLAN
Diagnostics ordered:
Therapeutics (drug, dose, route, frequency, duration):
Patient education (specific, teach-back verified):
Referrals / consults:
Follow-up interval and red-flag return precautions:
Health maintenance items addressed today:

• Subjective — only what the patient, family, or caregiver reports. Quotes belong here. Never place exam findings or your interpretation here.
• Objective — only measurable, observable, reproducible data: vitals, exam findings, labs, imaging, validated scores. "Patient appears anxious" is a judgment; "pacing, tremor, HR 104, GAD-7 of 16" is objective.
• Assessment — your synthesis, not a repetition of data. Name the diagnosis, cite the data that supports it, and say why the differentials are less likely. This is the section faculty grade hardest.
• Plan — one plan item per problem, each specific enough to be executed by someone else: drug with dose and duration, the exact education given, the referral, the follow-up interval, and the return precautions.

S: 28 y/o female. "It burns when I pee and I keep running to
the bathroom." Onset 2 days, suprapubic pressure, urgency,
frequency q30min. Denies fever, flank pain, vaginal discharge,
nausea. No prior UTI. LMP 10 days ago. NKDA. No meds.

O: T 37.2, HR 84, BP 116/72, RR 16. Alert, no distress.
Abdomen soft, suprapubic tenderness, no CVA tenderness.
UA: leukocyte esterase positive, nitrites positive, WBC 30/hpf,
no casts. Urine hCG negative. Culture sent.

A: Acute uncomplicated cystitis (ICD-10 N30.00) - supported by
dysuria, urgency, frequency, suprapubic tenderness, and positive
nitrites with pyuria. Pyelonephritis less likely: afebrile, no
CVA tenderness, no systemic symptoms. Vaginitis less likely: no
discharge or pruritus. STI less likely but urine GC/CT sent.

P: 1) Nitrofurantoin 100 mg PO BID x 5 days.
   2) Phenazopyridine 200 mg PO TID x 2 days PRN; warned about
      orange urine and contact lens staining.
   3) Education: complete full course, 2-3 L fluids/day,
      void after intercourse, front-to-back hygiene. Teach-back
      completed on all four items.
   4) Return precautions: fever, flank pain, vomiting, or no
      improvement in 48 h.
   5) Follow-up: culture review in 48-72 h; office visit PRN.

1. Is every Subjective line something the patient could have said?
2. Is every Objective line measurable and free of interpretation?
3. Does the Assessment cite specific data, not just name a condition?
4. Are there at least two differentials with a reason each was ruled less likely?
5. Does every plan item include enough detail for another clinician to execute it unchanged?
6. Is there a follow-up interval and an explicit red-flag return precaution?
7. Did you document teach-back rather than "patient educated"?
8. Is there no protected health information in a shared or graded document?