SOAP Notes for Nurses: Examples, Template and Charting Tips

SOAP notes help you organize patient information in a clear, clinical way.

They are not only for providers.

Nurses use SOAP-style documentation in clinical paperwork, progress notes, care coordination, case management, outpatient visits, school nursing, home health, community health, and some EHR note fields.

The point is simple: show what the patient said, what you observed, what you think is happening, and what you did next.

What is a SOAP note?

A SOAP note is a structured clinical note organized into four sections:

• Subjective
• Objective
• Assessment
• Plan

It helps the nurse separate patient-reported information from observed or measured findings.

That matters.

A note that mixes everything together can become vague fast.

A SOAP note keeps your thinking organized.

It also helps another nurse understand what happened, what changed, what you did, and what needs follow-up.

What SOAP means in nursing

SOAP is not just a form.

It is a thinking structure.

The format pushes you to ask:

What did the patient report?
What did I observe or measure?
What does it mean from a nursing perspective?
What did I do or plan to do next?

That is why SOAP notes can help nursing students.

They force you to move from data collection to clinical judgment.

For more clinical judgment practice, see NurseZee’s NCLEX prioritization guide and NCLEX prep guide.

SOAP note vs nursing progress note

A nursing progress note is any note that describes patient status, care provided, response to care, and follow-up.

SOAP is one way to structure that note.

Some facilities use SOAP.

Others use narrative notes, DAR, PIE, SBAR, flowsheets, care plans, or EHR-specific templates.

The format may differ, but the core rule stays the same.

Document clearly, accurately, timely, and within your scope.

SOAP note vs SBAR

SOAP and SBAR are related, but they are not the same.

SOAP is mainly a documentation format.

SBAR is mainly a communication format.

SBAR stands for:

• Situation
• Background
• Assessment
• Recommendation

Use SBAR when you call a provider, hand off care, or escalate a change in condition.

Use SOAP when you document the assessment, interpretation, action, and follow-up.

Example connection

SBAR call:
S: Patient has new shortness of breath.
B: Admitted with pneumonia, on 2 L nasal cannula.
A: SpO2 dropped to 88%, RR 28, crackles increased.
R: Request evaluation and updated orders.

SOAP note after the call:

S: Patient reports, "I can't catch my breath."
O: RR 28, SpO2 88% on 2 L NC, HR 116, increased work of breathing, crackles bilateral bases.
A: Worsening oxygenation and respiratory distress.
P: Raised HOB, applied oxygen per protocol, notified provider using SBAR, received new orders, will reassess respiratory status and SpO2 in 15 minutes.

SOAP note sections explained

S: Subjective

Subjective data comes from the patient or another source.

It includes what the patient says, feels, reports, denies, or describes.

Common subjective data:

• Pain rating
• Symptoms
• Onset
• Patient concerns
• Patient goals
• Nausea, dizziness, weakness, shortness of breath
• Medication side effects the patient reports
• Sleep, appetite, bowel pattern, urinary symptoms
• Emotional concerns
• Family or caregiver report when appropriate

Use quotation marks for important patient statements.

Example:

S: Patient reports, "My chest feels tight when I walk to the bathroom." Rates chest tightness 6/10 with activity and denies nausea.

Do not document your opinion as subjective data.

Bad example:

S: Patient is being dramatic about pain.

Better example:

S: Patient reports pain 9/10 and states, "The pain is worse than it was this morning."

O: Objective

Objective data is what you can observe, measure, assess, or verify.

Common objective data:

• Vital signs
• SpO2
• Pain behavior you observe
• Lung sounds
• Heart rhythm
• Wound appearance
• Drainage amount and type
• Intake and output
• Level of consciousness
• Skin color and temperature
• Edema
• Blood glucose
• Lab values available to you
• Medication administration
• Mobility assessment
• Fall precautions in place
• Response after intervention

Example:

O: BP 150/88, HR 104, RR 22, SpO2 94% on room air. Patient guarding abdomen and grimacing with movement. Incision intact with no active drainage.

Objective data should be specific.

Vague:

O: Patient looks bad.

Better:

O: Patient pale and diaphoretic, RR 30, HR 128, BP 88/52, SpO2 89% on room air.

A: Assessment

The assessment section is your nursing interpretation.

This is where many students get stuck.

You do not need to diagnose a medical condition.

You do need to connect the cues.

Your assessment may include:

• Priority nursing concern
• Change from baseline
• Response to intervention
• Progress toward a goal
• Risk concern
• Need for escalation
• Nursing diagnosis when required by your instructor
• Clinical judgment statement

Examples:

A: Acute pain not adequately controlled after ambulation.

A: Respiratory status worsening compared with morning assessment.

A: Blood glucose improved after treatment; patient remains at risk for recurrent hypoglycemia.

A: Patient understands wound care steps but needs reinforcement on signs of infection.

Avoid diagnosing outside your scope.

Instead of:

A: Patient has pulmonary embolism.

Use:

A: Sudden dyspnea, pleuritic chest pain, tachycardia, and low SpO2 are concerning for acute respiratory/circulatory complication; provider notified.

P: Plan

The plan section documents what you did and what comes next.

This may include:

• Nursing interventions
• Medications given as ordered
• Provider notification
• Patient education
• Safety actions
• Reassessment plan
• Monitoring plan
• Referrals or consults
• Follow-up labs or diagnostics if ordered
• Care plan updates
• Patient response

Example:

P: Administered prescribed acetaminophen. Repositioned patient with pillow support. Taught splinting during coughing. Will reassess pain in 60 minutes and notify provider if pain remains above goal.

The plan should not be empty.

If nothing else, document your reassessment plan.

Nursing SOAP note template

Use this template for clinical paperwork or practice.

Adjust it to your instructor or facility requirements.

Date/time:
Patient initials or identifier per policy:
Location/unit:
Reason for note:

S: Patient reports [...]. Patient denies [...]. Patient states "[...]". Pain [...]/10 at [...]. Symptoms began [...].

O: Vital signs [...]. Assessment findings [...]. Relevant labs/diagnostics [...]. Interventions already in place [...]. Safety findings [...].

A: Nursing interpretation of findings: [...]. Priority concern: [...]. Response to current treatment: [...]. Risk concern: [...].

P: Nursing interventions completed [...]. Provider notified [...]. Patient education provided [...]. Orders followed [...]. Reassessment plan [...]. Patient response [...].

Short SOAP note template

Use this when your note needs to be brief.

S: Patient reports [...].
O: [Focused assessment and measurable findings].
A: [Nursing interpretation or problem status].
P: [Action taken, teaching, notification, and reassessment].

Student SOAP note template

Nursing school may require more detail.

S: Patient statement, symptom description, relevant history, pain score, concerns, and patient goals.

O: Vital signs, focused assessment, head-to-toe findings relevant to the problem, medications, labs, lines/drains/tubes, mobility, skin, safety, and data trends.

A: Nursing diagnosis or priority nursing problem, related factors, evidence, and clinical judgment statement.

P: Interventions, patient education, safety actions, collaboration, evaluation criteria, and when you will reassess.

How to write a SOAP note step by step

Step 1: Start with the reason for the note

Know why you are writing.

Common reasons:

• New symptom
• Change in condition
• Pain reassessment
• Fall
• Patient refusal
• Wound assessment
• Medication response
• Discharge teaching
• Provider notification
• Clinical assignment
• Care plan update

Your note should have a focus.

Do not document every detail if the note is about one specific issue.

Step 2: Separate subjective and objective data

This is the most common student mistake.

Patient-reported symptoms go under S.

Measured and observed findings go under O.

Example:

S: Patient reports dizziness when standing.
O: BP 118/76 supine and 94/58 standing. Patient unsteady when rising from bed.

Do not put “patient dizzy” in objective unless you observed signs that support it.

Step 3: Identify the nursing concern

Ask:

What is the safest nursing concern based on the data?

Examples:

• Pain not controlled
• Risk for fall
• Possible fluid volume deficit
• Worsening respiratory status
• Knowledge deficit
• Skin breakdown risk
• Impaired mobility
• Hypoglycemia treated, monitor for recurrence

This goes in A.

Step 4: Document action and follow-up

A SOAP note is incomplete without action.

Include what you did and what you will check next.

Example:

P: Assisted patient back to bed, placed call light within reach, activated bed alarm, notified charge nurse, and will reassess orthostatic symptoms before next ambulation.

Step 5: Keep it factual

Good charting is clear and neutral.

Avoid blaming, labeling, or guessing.

Instead of:

Patient is noncompliant and refuses to listen.

Use:

Patient declined prescribed ambulation after education on post-op mobility benefits and risks. Patient stated, "I am too tired right now." Will reoffer ambulation after rest period.

SOAP note examples for nurses

Example 1: Acute pain after surgery

Situation

A patient is 8 hours post-op after abdominal surgery and reports worsening incisional pain.

SOAP note

S: Patient reports incisional pain 8/10 and states, "It hurts more when I cough." Denies nausea and shortness of breath.

O: BP 142/86, HR 104, RR 20, SpO2 96% on room air, temp 37.2°C. Patient guarding abdomen and grimacing with movement. Incision dressing clean, dry, and intact. Abdomen soft with expected tenderness near incision.

A: Acute post-op pain increased with coughing and movement. No current signs of respiratory distress or active incisional bleeding.

P: Administered prescribed pain medication per MAR. Taught patient to splint incision with pillow when coughing. Repositioned with HOB elevated and call light within reach. Will reassess pain and sedation level per policy.

Why this works

The note includes pain score, focused assessment, nursing interpretation, intervention, teaching, and reassessment.

Example 2: Shortness of breath

Situation

A patient admitted with pneumonia reports increased shortness of breath.

SOAP note

S: Patient reports, "I feel more short of breath than earlier." Denies chest pain. States breathing worsens when lying flat.

O: RR 28, HR 118, BP 136/82, SpO2 88% on 2 L NC. Increased work of breathing noted. Crackles heard in bilateral lower lobes. Patient sitting upright and speaking in short phrases.

A: Worsening oxygenation and increased work of breathing compared with prior assessment.

P: Raised HOB. Applied oxygen per protocol and facility policy. Notified provider using SBAR and updated charge nurse. New orders received. Will monitor respiratory status, SpO2, and response to interventions closely.

Why this works

The note identifies a change from baseline, documents objective respiratory findings, shows escalation, and includes follow-up monitoring.

Example 3: Hypoglycemia

Situation

A patient with diabetes reports shakiness before lunch.

SOAP note

S: Patient reports, "I feel shaky and sweaty." States breakfast intake was poor. Denies chest pain or shortness of breath.

O: Patient diaphoretic with mild hand tremor. Blood glucose 58 mg/dL. Alert and able to swallow. Skin warm and moist. Meal tray at bedside.

A: Symptomatic hypoglycemia with patient alert and able to take oral carbohydrate.

P: Treated per hypoglycemia protocol with fast-acting carbohydrate. Stayed with patient and rechecked blood glucose per policy. Blood glucose improved to 82 mg/dL and symptoms decreased. Notified provider per protocol and reinforced importance of meal intake after insulin.

Why this works

The note documents the symptom, glucose value, safety assessment, protocol-based action, reassessment, and teaching.

Example 4: Wound assessment

Situation

A patient has a surgical wound with new drainage.

SOAP note

S: Patient reports increased tenderness around incision and states, "The dressing feels wetter than usual." Rates pain 5/10 at incision site.

O: Temp 38.1°C, HR 102. Dressing with moderate serosanguineous drainage. Incision edges approximated with mild redness extending approximately 1 cm from wound edge. No odor noted. Drainage amount increased compared with previous note.

A: Increased drainage and mild redness with low-grade fever; wound requires provider follow-up and continued monitoring.

P: Reinforced dressing per policy. Marked drainage outline with date/time if consistent with facility policy. Notified provider and charge nurse. Will monitor temperature, drainage amount, wound appearance, and pain.

Why this works

The note describes wound findings clearly instead of using vague language like "looks infected."

Example 5: Patient fall

Situation

A patient is found sitting on the floor beside the bed.

SOAP note

S: Patient states, "I tried to get to the bathroom and slipped." Reports right hip pain 4/10. Denies hitting head.

O: Patient found sitting on floor beside bed at 0210. Alert and oriented to person, place, and time. No visible bleeding. Right hip tender to palpation. Vital signs: BP 132/78, HR 96, RR 18, SpO2 97% on room air. Bed alarm was sounding on entry.

A: Unwitnessed fall with reported right hip pain. Patient requires post-fall assessment and provider notification per policy.

P: Stayed with patient, called for assistance, completed focused assessment, notified charge nurse and provider, and followed post-fall protocol. Implemented fall precautions, including bed low, call light within reach, nonskid socks, and bed alarm. Will continue neuro checks and pain reassessment per policy.

Why this works

The note documents what was found, what the patient reported, assessment findings, notifications, safety actions, and follow-up.

Example 6: Patient refuses medication

Situation

A patient refuses a scheduled antihypertensive.

SOAP note

S: Patient states, "I do not want that blood pressure pill because it made me dizzy yesterday." Denies headache, chest pain, and shortness of breath.

O: BP 164/92, HR 88, RR 18, SpO2 98% on room air. Patient alert and oriented. Medication education provided using plain language. Patient verbalized understanding and continued to decline medication.

A: Patient declined scheduled antihypertensive after education. Blood pressure elevated; provider notification indicated per facility policy.

P: Held medication due to patient refusal. Notified provider and documented refusal in MAR per policy. Reinforced signs and symptoms to report. Will recheck BP as ordered and continue to monitor.

Why this works

The note avoids judgmental wording and documents education, patient decision, provider notification, and monitoring.

Example 7: Patient education

Situation

A patient is learning discharge wound care.

SOAP note

S: Patient states, "I am nervous I will do the dressing wrong at home." Reports spouse can assist with dressing change.

O: Patient watched wound care demonstration and then performed return demonstration using clean technique with verbal prompting. Patient correctly identified hand hygiene and when to call provider but needed reinforcement on dressing disposal.

A: Patient demonstrates partial understanding of wound care and needs reinforcement before discharge.

P: Reviewed wound care steps, signs of infection, supply storage, and when to call provider. Provided written instructions per discharge packet. Will repeat return demonstration before discharge and include spouse if available.

Why this works

The note shows what was taught, how understanding was evaluated, and what teaching remains.

Example 8: Anxiety before procedure

Situation

A patient is anxious before a scheduled procedure.

SOAP note

S: Patient states, "I am scared about the procedure." Reports not understanding what will happen after transport. Denies pain.

O: Patient tearful, hands trembling, asks repeated questions about procedure timing. BP 148/84, HR 106, RR 22. Consent form present in chart. Procedure teaching packet at bedside.

A: Anxiety related to procedure and uncertainty about next steps. Patient needs clarification and emotional support.

P: Used calm communication, encouraged questions, reviewed nursing preparation steps within scope, and notified procedural nurse/provider that patient has additional questions about procedure details. Stayed with patient until transport arrived.

Why this works

The note supports the patient without documenting provider-level informed consent teaching as a nursing responsibility.

Focused SOAP templates by situation

Pain reassessment SOAP template

S: Patient reports pain [...]/10 at [location], described as [...]. States pain is [better/worse/unchanged] after intervention.

O: Patient [grimacing/relaxed/resting/guarding]. Vital signs [...]. Sedation/respiratory status [...]. Intervention given at [...].

A: Pain [improved/not improved/partially improved] after intervention. No adverse effects noted / adverse effect noted [...].

P: Continue current plan / notify provider / use nonpharmacologic intervention / reassess in [...].

Respiratory SOAP template

S: Patient reports [...]. Denies/reports chest pain, dizziness, cough, or sputum changes.

O: RR [...], SpO2 [...], oxygen device [...], lung sounds [...], work of breathing [...], skin color [...].

A: Respiratory status [stable/worsening/improving] based on [...]. Priority concern [...].

P: Interventions [...]. Provider/RT notified [...]. Reassessment plan [...].

Wound SOAP template

S: Patient reports pain, tenderness, drainage concerns, odor, fever/chills, or dressing discomfort.

O: Wound location, size if measured per policy, edges, wound bed, drainage amount/color/odor, peri-wound skin, dressing status, temperature, pain score.

A: Wound status compared with prior assessment. Concern for delayed healing, increased drainage, skin breakdown, or infection risk.

P: Dressing change/reinforcement per order and policy, provider notification, wound consult, patient teaching, reassessment plan.

Fall SOAP template

S: Patient statement about what happened, pain, dizziness, head strike, loss of consciousness, or symptoms before fall.

O: Found position, time, mental status, injuries, vital signs, mobility status, environment, assistive devices, safety devices.

A: Fall with/without injury concern. Risk factors identified. Need for post-fall protocol.

P: Stay with patient, call for assistance, notify provider/charge nurse/family per policy, complete post-fall assessment, implement fall precautions, monitor per protocol.

Patient refusal SOAP template

S: Patient states reason for refusal in their own words.

O: Current assessment data relevant to refusal. Education provided. Patient capacity/orientation if relevant. Patient response after education.

A: Patient declined [medication/treatment/procedure/care] after education. Risk/priority concern [...].

P: Notify provider as needed, document refusal in correct area, update care plan, continue monitoring, reoffer when appropriate.

What to include in nursing SOAP notes

Include patient identifiers according to policy

Use the identifier required by your school or facility.

For clinical paperwork, this often means initials, age, sex, room number, or a simulated identifier.

Do not include unnecessary protected health information in assignments.

Include date and time

Clinical notes need a time anchor.

Use facility-approved time format.

When documenting a change in condition, time matters.

Example:

1430: Patient reported new shortness of breath...

Include relevant baseline and trend data

A single number can mislead.

Trends show change.

Example:

O: SpO2 decreased from 95% on 2 L NC at 0800 to 88% on 2 L NC at 1015.

That is stronger than:

O: SpO2 low.

Include patient response

Document whether your intervention worked.

Examples:

Patient reports pain decreased from 8/10 to 4/10 45 minutes after medication.

SpO2 improved from 88% to 94% after HOB raised and oxygen adjusted per protocol.

Patient demonstrated correct inhaler technique after teaching.

Include escalation

If you notify someone, document who, when, why, and response.

Weak:

MD aware.

Better:

Provider Smith, NP notified at 1018 of SpO2 88% on 2 L NC, RR 28, and increased work of breathing. New orders received for [...].

If no new orders:

Provider notified at 1018; no new orders received. Continue monitoring and notify for worsening symptoms per provider instruction.

Include teaching and understanding

Do not only write “education provided.”

Document the topic and response.

Example:

Taught patient to use call light before getting out of bed due to dizziness and fall risk. Patient verbalized understanding and demonstrated call light use.

Include safety actions

This is especially important for falls, confusion, seizures, suicide risk, aspiration, restraints, or equipment concerns.

Example:

Bed in lowest position, call light within reach, bed alarm on, nonskid socks in place, hourly rounding continued.

What not to include in SOAP notes

Do not include blame

Avoid:

Patient was lazy and refused to walk.

Use:

Patient declined ambulation at 1400 and stated, "I am too tired right now." Educated patient on post-op mobility benefits and risks. Will reoffer ambulation after rest period.

Do not include insults or labels

Avoid words like:

• Dramatic
• Difficult
• Noncompliant
• Lazy
• Drug-seeking
• Crazy
• Rude
• Manipulative

Use objective facts.

Example:

Patient raised voice and stated, "I want to speak to the charge nurse." Charge nurse notified.

Do not speculate

Avoid:

Patient probably fell because family left shoes on floor.

Use:

Patient found sitting on floor beside bed. Shoes observed near bedside. Patient stated, "I slipped when I stood up."

Do not copy and paste without checking

Copy-forward charting can create errors.

If the wound changed, the pain improved, or the oxygen device changed, the note must change.

Do not document before care is done

Never chart care early.

Document after you complete the assessment, intervention, teaching, notification, or reassessment.

Do not use unsafe abbreviations

Only use approved abbreviations from your facility or school.

Avoid abbreviations that can be misread.

When in doubt, spell it out.

Common SOAP note mistakes students make

Mistake 1: Mixing subjective and objective data

Incorrect:

S: Patient has RR 28 and SpO2 88%.

Correct:

S: Patient reports, "I feel short of breath."
O: RR 28 and SpO2 88% on 2 L NC.

Mistake 2: Writing an assessment that repeats the data

Weak:

A: Patient has pain 8/10.

Better:

A: Acute post-op pain not controlled at current comfort goal.

Mistake 3: Leaving out reassessment

Incomplete:

P: Gave pain medication.

Better:

P: Administered prescribed pain medication per MAR. Will reassess pain, sedation, and respiratory status per policy.

Mistake 4: Documenting vague findings

Weak:

O: Wound looks worse.

Better:

O: Wound drainage increased from scant to moderate serosanguineous drainage since previous dressing assessment. Mild peri-wound redness noted.

Mistake 5: Charting opinions

Weak:

A: Patient is attention-seeking.

Better:

A: Patient reports anxiety and repeated concerns about procedure. Needs reassurance and clarification of next steps.

Mistake 6: Forgetting scope

Nurses can document nursing assessment and concerns.

Do not write medical diagnoses you are not authorized to make.

Better:

A: Findings concerning for possible acute deterioration; provider notified.

Mistake 7: Writing too much unrelated information

A SOAP note should focus on the problem.

If the note is about wound drainage, do not include a full head-to-toe assessment unless required.

Mistake 8: Not documenting patient response to education

Weak:

P: Educated patient.

Better:

P: Reviewed signs of infection and wound care steps. Patient correctly stated two signs to report: fever and increased drainage.

Charting tips for nurses

Be timely

Chart as close to the event as possible.

Late charting increases the risk of missing details.

If you must enter a late note, follow facility policy.

Be specific

Specific charting helps the next nurse.

Weak:

Patient doing better.

Better:

Patient reports pain decreased from 7/10 to 3/10 and is resting with eyes closed. RR 16, SpO2 97% on room air.

Be objective

Use facts, not judgments.

Weak:

Patient was angry for no reason.

Better:

Patient raised voice and stated, "No one has told me when I am going home." Reviewed discharge plan and notified case manager.

Use patient quotes when helpful

Quotes help capture symptoms, refusal, threats, confusion, pain, or concerns.

Example:

S: Patient states, "The pain started in my chest and is going down my left arm."

Do not overuse quotes for routine statements.

Document notifications clearly

Include:

• Who you notified
• Time notified
• Reason
• Data reported
• Response or orders
• Your follow-up

Example:

P: Provider notified at 1535 of BP 88/52, HR 124, urine output 15 mL/hr, and new confusion. Orders received. Charge nurse updated. Will monitor VS every 15 minutes per order.

Document refusals without judgment

A patient can refuse care.

Your job is to assess, educate, notify when needed, and document.

Example:

Patient declined ordered ambulation after education on post-op mobility and DVT prevention. Patient stated, "I want to wait until my daughter arrives." Provider not notified at this time per unit policy; will reoffer within 1 hour.

Document pain reassessment

Pain documentation is not complete when the medication is given.

You also need response.

Example:

Pain reassessed 45 minutes after medication. Patient reports pain decreased from 8/10 to 4/10. Patient awake, RR 16, SpO2 96% on room air.

Document safety checks

For high-risk patients, chart safety actions.

Examples:

• Fall precautions
• Seizure precautions
• Aspiration precautions
• Suicide precautions according to policy
• Restraint monitoring according to policy
• Bed alarm
• Call light within reach
• Side rails per policy
• Mobility assistance

Document patient teaching with teach-back

Teach-back is stronger than “patient verbalized understanding.”

Example:

Patient demonstrated inhaler technique and correctly stated to rinse mouth after steroid inhaler use.

Document abnormal findings and follow-up

If you chart an abnormal finding, chart what you did about it.

Example:

O: Temp 38.5°C, HR 112.
A: Fever and tachycardia in post-op patient require provider follow-up.
P: Provider notified; new orders received for labs and acetaminophen. Will reassess temperature in 1 hour.

EHR charting tips for SOAP notes

Know where the data belongs

Many EHRs separate documentation into flowsheets, MAR, notes, care plans, education tabs, and provider communication fields.

Do not duplicate everything in the SOAP note.

Use the note to explain the clinical story.

Example:

O: See flowsheet for full vital signs. Focused respiratory assessment: RR 28, SpO2 88% on 2 L NC, increased work of breathing, crackles bilateral bases.

Only use references like “see flowsheet” if your facility allows it.

Avoid copy-forward errors

Before signing, check:

• Date and time
• Oxygen device
• Lines and drains
• Wound status
• Pain score
• Diet order
• Mobility level
• Isolation status
• Medication changes
• Patient education status

Check the right patient record

Wrong-chart documentation is a serious safety problem.

Before documenting, verify the patient record.

Use templates carefully

Templates save time.

They can also create false documentation if you leave inaccurate default text.

Delete anything you did not assess or do.

Keep the note readable

Long blocks of text are hard to scan.

Use short sentences.

Use the SOAP labels.

Use focused findings.

Legal and safety considerations

Documentation is part of patient care

Your note helps communicate care across the team.

It may also be reviewed for quality, billing support, audits, incident review, or legal proceedings.

That does not mean you should write defensively.

It means you should write accurately.

Follow HIPAA and privacy rules

Only access and document information needed for patient care and your role.

For school assignments, remove unnecessary identifiers according to school and facility policy.

Correct errors according to policy

Do not delete, hide, or alter documentation improperly.

Electronic systems usually track corrections.

Paper chart corrections require facility-specific steps.

Use late entries correctly

If you forgot to chart something, follow late-entry policy.

A late entry should usually include the current date/time of entry and the actual time the care occurred, depending on policy.

Example format:

Late entry for 0930: Patient reported nausea after breakfast. Emesis 100 mL clear fluid. Administered prescribed antiemetic per MAR and reassessed at 1015; patient reported nausea improved.

Avoid incident-report language in the medical record

Follow facility policy.

In many facilities, you document the patient assessment and care in the chart, but you do not write “incident report completed” in the medical record.

Ask your instructor or supervisor.

SOAP notes and the nursing process

SOAP lines up well with the nursing process.

This is why SOAP helps with clinical judgment.

It makes you show your thinking.

SOAP and NCLEX clinical judgment

The NCSBN Clinical Judgment Measurement Model uses steps such as recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

SOAP fits that flow.

S/O: Recognize cues.
A: Analyze cues and prioritize the nursing concern.
P: Generate solutions and take action.
Follow-up: Evaluate outcomes.

For more NGN practice, use NurseZee’s practice questions and NCLEX prep guide.

SOAP note examples by clinical area

Med-surg SOAP example

S: Patient reports abdominal pain 6/10 and nausea after breakfast. States, "I feel bloated."

O: Abdomen distended, bowel sounds hypoactive in all quadrants, no emesis at this time. BP 138/82, HR 98, RR 18, temp 37.3°C. Patient post-op day 2 after bowel surgery.

A: Abdominal distention and nausea with hypoactive bowel sounds; requires continued monitoring and provider follow-up.

P: Held oral intake until clarified with provider per unit protocol. Notified provider of findings. Encouraged patient to remain NPO until further instruction. Will monitor nausea, emesis, abdominal assessment, and vital signs.

Emergency department SOAP example

S: Patient reports chest pressure 7/10 that started 30 minutes ago while walking. States pain radiates to left arm. Reports nausea and sweating.

O: Patient diaphoretic and pale. BP 158/92, HR 112, RR 24, SpO2 95% on room air. ECG obtained per protocol and provider notified.

A: Acute chest pain with concerning associated symptoms. Requires urgent evaluation.

P: Followed chest pain protocol, placed patient on monitor, obtained ECG, established IV access per policy, notified provider, and remained with patient for ongoing assessment.

Pediatric SOAP example

S: Parent reports child has had fever and decreased intake since last night. Parent states, "She only had one wet diaper this morning."

O: Child quiet but arousable. Temp 38.6°C, HR 138, RR 30. Mucous membranes dry. One wet diaper reported since morning. Weight documented in chart.

A: Fever with decreased intake and decreased urine output; concern for dehydration risk.

P: Notified provider of intake/output concern and assessment findings. Encouraged small frequent fluids as appropriate and per order. Will monitor temperature, intake, output, and activity level.

OB postpartum SOAP example

S: Patient reports increased perineal discomfort and feeling "lightheaded" when standing. Denies chest pain or shortness of breath.

O: Fundus firm at umbilicus. Lochia moderate rubra with small clots. BP 100/62 sitting, HR 112. Patient pale when standing. Perineal ice pack in place.

A: Postpartum patient with lightheadedness and tachycardia; bleeding and orthostatic symptoms require close follow-up.

P: Assisted patient back to bed, instructed not to ambulate without assistance, notified provider and charge nurse, and will monitor bleeding, fundus, vital signs, and symptoms per policy.

Mental health SOAP example

S: Patient states, "I feel overwhelmed and I do not want to talk to anyone." Denies current plan to harm self when asked directly.

O: Patient sitting alone, limited eye contact, soft speech, tearful. Accepted scheduled medication. Safety checks continued per unit policy.

A: Depressed mood with withdrawal. Patient denies current self-harm plan but requires continued safety monitoring and therapeutic communication.

P: Provided calm one-to-one support, encouraged patient to attend group when ready, notified assigned nurse of statements and affect, and continued safety checks per policy.

Home health SOAP example

S: Patient reports increased shortness of breath when walking from bedroom to kitchen. States, "My legs feel more swollen this week."

O: Bilateral lower extremity edema 2+, weight up 4 lb from last visit per home log, lungs with crackles at bases, SpO2 93% on room air, medication bottles reviewed.

A: Increased edema, weight gain, and exertional dyspnea; concern for fluid volume excess and need for provider follow-up.

P: Reviewed low-sodium diet and daily weight instructions. Notified provider of findings. Reinforced when to seek urgent care. Will follow agency protocol for next visit and monitoring.

SOAP note wording bank

Use these phrases as starting points.

Do not copy them if they do not match your patient.

Subjective phrases

Patient reports...
Patient states, "..."
Patient denies...
Patient describes pain as...
Patient reports symptoms began...
Patient states symptoms improve with...
Patient states symptoms worsen with...
Caregiver reports...
Parent reports...
Patient verbalizes concern about...

Objective phrases

Vital signs...
Patient observed...
Focused assessment reveals...
Skin warm/dry/pale/diaphoretic...
Lung sounds...
Bowel sounds...
Incision/wound...
Drainage...
Patient ambulated...
Blood glucose...
Patient demonstrated...

Assessment phrases

Findings consistent with...
Patient response indicates...
Symptoms improved after...
Symptoms not relieved by...
Change from baseline noted...
Priority concern is...
Patient remains at risk for...
Requires provider follow-up due to...
Teaching effective as evidenced by...
Teaching requires reinforcement because...

Plan phrases

Administered prescribed...
Repositioned...
Implemented fall precautions...
Notified provider...
Updated charge nurse...
Provided education on...
Patient demonstrated...
Will reassess...
Will continue to monitor...
Followed facility protocol for...
Documented in MAR/flowsheet per policy...

SOAP note mini practice

Practice 1

A patient says pain is 9/10 after ambulation. You observe guarding and HR 108. The dressing is dry. Pain medication is available as ordered.

Sample answer

S: Patient reports incisional pain 9/10 after ambulation and states, "It is sharp when I move."

O: HR 108, RR 20, patient guarding incision. Dressing clean, dry, and intact. No active bleeding noted.

A: Acute post-op pain increased after activity.

P: Administered prescribed pain medication per MAR, assisted patient to comfortable position, encouraged splinting with movement, and will reassess pain and sedation per policy.

Practice 2

A patient with heart failure reports more shortness of breath. Weight is up 3 lb in 2 days. Crackles are present.

Sample answer

S: Patient reports increased shortness of breath with walking and states, "My shoes feel tight today."

O: Weight increased 3 lb in 2 days. Bilateral crackles at lung bases. 2+ ankle edema. SpO2 93% on room air.

A: Findings suggest worsening fluid volume status and require provider follow-up.

P: Notified provider of weight gain, crackles, edema, and shortness of breath. Reinforced low-sodium diet and daily weight monitoring. Will monitor respiratory status, edema, intake/output, and response to orders.

Practice 3

A patient refuses to use the call light and keeps trying to get up alone.

Sample answer

S: Patient states, "I do not need help walking to the bathroom."

O: Patient attempted to get out of bed without assistance twice during shift. Gait unsteady when assisted to bathroom. Bed alarm activated. Call light within reach.

A: Patient at increased risk for fall due to unsteady gait and attempts to ambulate without assistance.

P: Reinforced need to call for assistance before getting up. Kept bed low, call light within reach, nonskid socks on, and bed alarm active. Notified charge nurse and continued frequent rounding.

Quick SOAP note checklist

Before signing your note, check:

• Did I use the correct patient record?
• Did I include date and time?
• Did I separate subjective and objective data?
• Did I document focused assessment findings?
• Did I include abnormal findings and trends?
• Did I write a nursing assessment, not a medical diagnosis outside scope?
• Did I document interventions?
• Did I document patient response?
• Did I document provider notification when needed?
• Did I include teaching and teach-back if education occurred?
• Did I avoid judgmental wording?
• Did I follow facility or school policy?

Frequently asked questions about SOAP notes for nurses

Do nurses write SOAP notes?

Yes. Nurses may use SOAP notes in clinical school assignments, outpatient settings, community health, home health, case management, specialty clinics, and some hospital EHR notes. Not every unit uses SOAP, so follow facility policy.

What does SOAP stand for in nursing?

SOAP stands for Subjective, Objective, Assessment, and Plan. Subjective is what the patient reports. Objective is what the nurse observes or measures. Assessment is the nursing interpretation. Plan is the action and follow-up.

What goes in the subjective section of a SOAP note?

Subjective data includes patient-reported symptoms, concerns, pain score, onset, description, and statements. Use quotes when the exact words matter.

What goes in the objective section of a SOAP note?

Objective data includes vital signs, assessment findings, observations, wound appearance, oxygen saturation, lab values available to you, blood glucose, intake/output, mobility findings, and measurable patient responses.

What goes in the assessment section of a nursing SOAP note?

The assessment section includes your nursing interpretation of the data. This may be a priority concern, response to treatment, nursing diagnosis, change from baseline, or risk statement.

What goes in the plan section of a SOAP note?

The plan includes nursing interventions, provider notification, medications given as ordered, patient education, safety actions, monitoring, and reassessment.

Can nursing students use SOAP notes for clinical paperwork?

Yes, if the instructor allows it. SOAP notes help students organize assessment findings and show clinical reasoning. Always remove patient identifiers according to school and facility policy.

Is a SOAP note the same as a care plan?

No. A SOAP note documents a specific patient issue or encounter. A care plan is broader and includes nursing diagnoses, goals, interventions, and evaluation over time. SOAP notes can support care plan updates.

Should I write a medical diagnosis in the assessment section?

Usually no, unless you are documenting an established diagnosis from the chart. Nurses should not diagnose outside their scope. Use nursing concerns and objective findings, such as “worsening respiratory status” or “fall risk due to unsteady gait.”

How long should a SOAP note be?

A SOAP note should be long enough to tell the clinical story and short enough to stay focused. A routine note may be a few lines. A change-in-condition note needs more detail.

Can I use abbreviations in SOAP notes?

Use only approved abbreviations from your facility or school. If an abbreviation could be misread, spell it out.

How do I document that I called the provider?

Document the time, person notified, patient data reported, reason for notification, response, orders received if any, and your follow-up.

What is the biggest mistake in SOAP notes?

The biggest mistake is documenting data without action. If you chart an abnormal finding, document what you did, who you notified if needed, and when you reassessed.

Are SOAP notes used on the NCLEX?

The NCLEX may not ask you to write a SOAP note, but SOAP thinking supports clinical judgment. It helps you recognize cues, analyze data, choose a priority, take action, and evaluate outcomes.

Where can I practice nursing documentation and clinical judgment?

Use clinical scenarios, instructor feedback, and NCLEX-style case questions. NurseZee’s practice questions can help you strengthen cue recognition and priority thinking.

Final thoughts

A SOAP note should make patient care easier to understand.

It should not be a wall of vague charting.

Keep it focused.

Keep it factual.

Separate what the patient said from what you observed.

Then show your nursing judgment: what the data means, what you did, and how you followed up.

That is the heart of safe nursing documentation.