Nursing SOAP Notes — Format, 15 Examples & Free Template

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. It was developed by Dr. Lawrence Weed in the 1960s as part of the Problem-Oriented Medical Record and remains the dominant clinical note format used by nurses, nurse practitioners, physicians, therapists, and social workers.

• S — Subjective: the patient's own report — symptoms, history, complaints. Use direct quotes when possible.
• O — Objective: measurable, observable data — vitals, physical exam findings, lab and imaging results.
• A — Assessment: your clinical interpretation — the working diagnosis, differential, or nursing diagnosis (NANDA).
• P — Plan: what you did, ordered, taught, and will follow up on.

1. Header first. Date, time, patient identifier, and the reason for the encounter.
2. Subjective — capture the patient's voice. Chief complaint, HPI (using OLDCARTS: Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity), pertinent history and ROS.
3. Objective — record only what is measurable. Vital signs, general appearance, focused physical exam, relevant labs and imaging.
4. Assessment — state your clinical impression. Include the working diagnosis with ICD-10 or NANDA label, a short differential when appropriate, and the acuity ("stable," "improving," "worsening").
5. Plan — be specific and time-bound. Diagnostics ordered, medications with dose/route/frequency, non-pharmacologic interventions, patient education delivered, follow-up interval, and safety-netting instructions.
6. Sign and time-stamp. Include your credentials.

S: "The pain is a 4 out of 10 when I move, better when I lie still." Reports one episode of nausea last night, resolved after ondansetron. No dyspnea, no chest pain. Tolerated ice chips overnight.

O: T 37.2 °C, HR 84, BP 122/76, RR 16, SpO₂ 98% on room air. Alert and oriented ×4. Lungs clear bilaterally. Abdomen soft, non-distended, incision clean/dry/intact with steri-strips over RLQ port sites, no erythema. Bowel sounds present in all four quadrants. Passing flatus. Foley draining clear yellow urine 0.8 mL/kg/hr.

A: POD 1 s/p laparoscopic appendectomy, recovering as expected. Pain adequately controlled on multimodal analgesia. No signs of infection or ileus.

P: Advance to clear liquids as tolerated; ambulate ×3 today; continue scheduled acetaminophen and ibuprofen; oxycodone PRN for breakthrough. Remove Foley this morning per nurse-driven protocol. Incision care taught to patient and family. Discharge anticipated tomorrow if tolerating diet and voiding independently.

S: 58-year-old man returns for 3-month HTN follow-up. Denies headaches, chest pain, palpitations, dyspnea, edema, or vision changes. Reports "pretty good" adherence to lisinopril but admits to occasional missed doses on weekends. Home BP log shows morning readings averaging 138/86. DASH diet counseling from last visit "mostly followed." Exercising 3× weekly. No new medications.

O: BP 142/88 R arm seated after 5 min rest; repeat 140/86. HR 74, weight 92 kg (–1.4 kg from last visit), BMI 30.2. Cardiac RRR, no murmurs. Lungs clear. No peripheral edema. Labs from last week: BMP unremarkable, HbA1c 5.7%.

A: Essential hypertension (I10), uncontrolled — likely contributor is missed weekend doses. Overweight, at increased ASCVD risk (10-yr 12%).

P: Increase lisinopril 20 mg → 40 mg daily. Set up weekly text reminders through patient portal. Reinforce DASH and continue exercise; target loss 2–4 kg over 3 months. Home BP log twice daily for 2 weeks. Recheck in 4 weeks. Return sooner for BP > 180/110, chest pain, or neurologic symptoms.

S: 34-year-old woman on sertraline 100 mg daily for MDD × 8 weeks. Reports mood "quite a bit better," sleep improved from 4 to 6.5 hours, energy improving. Denies suicidal ideation or plan; contract for safety intact. Some residual anxiety at work. Adherence 100%. No side effects other than mild nausea in first 2 weeks, resolved.

O: PHQ-9 today: 8 (down from 18 at baseline). GAD-7: 10 (down from 15). Vital signs stable. Alert, cooperative, mood euthymic, affect congruent, thought process linear, no perceptual disturbance, judgment intact.

A: MDD (F32.1) — partial response to sertraline. GAD (F41.1) — partial response. No safety concerns.

P: Continue sertraline 100 mg for 4 more weeks; consider titration to 150 mg if PHQ-9 does not reach ≤5. Reinforce CBT engagement, weekly sessions ongoing. Sleep hygiene reviewed. Follow up in 4 weeks; portal message earlier if worsening. Safety plan reviewed.

Different clinical settings extend SOAP:

• SOAPIE: adds Intervention and Evaluation — commonly required in undergraduate nursing coursework.
• SOAPIER: adds an Revision element after Evaluation.
• DAR (Focus Charting): Data, Action, Response — popular in med-surg and hospital settings.
• APSO: reorders SOAP so the Assessment and Plan appear first — useful in EHRs where clinicians want the "so what" up top.
• PIE: Problem, Intervention, Evaluation — brief format used in some critical-care flowsheets.

Date/Time: __________          Patient ID: __________
Provider: __________           Reason for encounter: __________

S — Subjective
  Chief complaint:
  HPI (OLDCARTS):
  PMH / meds / allergies / social:
  ROS (pertinent positives + negatives):

O — Objective
  Vitals: T __  HR __  BP __  RR __  SpO2 __
  General:
  Focused exam:
  Labs / imaging:

A — Assessment
  1. Primary diagnosis (ICD-10 or NANDA):
  2. Differential:
  3. Acuity / trajectory:

P — Plan
  Diagnostics:
  Medications (name, dose, route, frequency):
  Non-pharmacologic interventions:
  Patient education:
  Follow-up:
  Safety-netting / return precautions:

Signature / credentials / time

• Mixing subjective and objective. "Patient looks anxious" belongs in Objective only if you specify observed behavior (e.g., "wringing hands, avoiding eye contact").
• Vague assessments. "Patient stable" is not an assessment. Name the problem, its trajectory, and any risk stratification.
• Plans without timeframes. Every plan element needs a "when" — dose intervals, follow-up windows, return precautions.
• Copy-forward errors. Copying yesterday's note without editing invites legal and safety risk.
• Missing patient education. Regulatory and reimbursement reviews look for documented teach-back.