SOAP Note Example and Template for Nursing Students

A SOAP note is a four-part clinical note that records what the patient tells you (Subjective), what you observe and measure (Objective), what you conclude (Assessment) and what happens next (Plan). Nursing programs assign SOAP notes because the format makes you show your clinical reasoning, not just your data.

Below you will find a copy-ready template, two complete examples with fictional patients, a step-by-step method and the mistakes that most often cost students points. The rules come from sources you can check, including the StatPearls review of SOAP notes and the Open RN nursing textbooks.

What Is a SOAP Note?

A SOAP note is a structured progress note that documents one patient encounter in a fixed order: Subjective, Objective, Assessment, Plan. StatPearls calls it both a documentation method and a framework for clinical reasoning. If your assessment does not follow from your data, the format makes the gap obvious.

The format traces back to Dr. Lawrence Weed, who built it into his problem-oriented medical record. He laid out that system in a 1968 New England Journal of Medicine article, "Medical Records That Guide and Teach". Physicians adopted it first. Today nurses and other members of the health care team write SOAP notes and their SOAPIE variant too.

As a nursing student, you will meet SOAP notes in two forms:

• RN-level notes in fundamentals, med-surg and clinical courses. The Assessment is usually a nursing diagnosis, and the Plan lists nursing interventions and goals.
• Provider-level notes in NP, MSN and DNP clinical courses. The Assessment is a medical diagnosis with a differential, and the Plan covers tests, treatment, referrals and follow-up.

Open RN's Nursing Fundamentals chapter on documentation draws the same line, and the two examples below show how each version reads.

The Four Parts of a SOAP Note

Each section answers one question, and the order matters because each part builds on the one before it.

Subjective: What the Patient Tells You

Subjective data is anything the patient, or someone close to the patient, reports: symptoms, feelings, history and concerns. StatPearls lists the usual contents:

• Chief concern (or chief complaint): the reason for the visit, ideally in the patient's own words. Patients often raise several concerns, and the first one is not always the most important, so ask about all of them.
• History of present illness (HPI): open with a one-line summary of age, sex and reason for the visit, then expand with the OLDCARTS mnemonic: Onset, Location, Duration, Characterization, Aggravating and Alleviating factors, Radiation, Temporal factors and Severity.
• Pertinent history: medical, surgical, family and social history that relates to the current problem. You do not need every relative's diagnoses.
• Review of systems: system-by-system questions that catch symptoms the patient did not mention.
• Medications and allergies: these can sit in Subjective or Objective, but each medication needs a name, dose, route and frequency.

For severity, Open RN's pain assessment chapter uses a 0 to 10 scale, with 0 meaning no pain, and its oxygenation chapter applies the same rating to shortness of breath.

Objective: What You Measure and Observe

Objective data is what you can see, hear, feel, measure or read in a result: vital signs, physical exam findings, lab values, imaging and other diagnostic data. StatPearls also places your review of other clinicians' documentation here.

A common student error is mixing up symptoms and signs. A symptom is the patient's own description, so it belongs in Subjective. A sign is a finding you detect, so it belongs in Objective. "My stomach hurts" is a symptom; "tenderness to palpation in the right lower quadrant" is a sign.

Assessment: What the Data Means

The Assessment is your synthesis of the subjective and objective data into a conclusion. List problems in order of priority. In an NP-style note, each problem gets a differential diagnosis ordered from most to least likely, with your reasoning, and StatPearls adds that the list should include less likely conditions that could cause harm if missed.

In an RN-level note, the Assessment is usually a nursing diagnosis statement. Open RN's chapter on nursing diagnosis explains its three parts: the problem, the related factor (phrased "related to") and the defining characteristics (phrased "as evidenced by"). For more practice with that structure, see this guide to writing nursing diagnoses for type 2 diabetes.

Do not simply copy your subjective and objective sections into the Assessment. Interpret them. Is the patient better or worse than last shift? Which finding drives your top problem?

Plan: What Happens Next

The Plan states what will be done about each problem in the Assessment. Per StatPearls, that means any tests needed (with the reason, and ideally the next step if the result is positive or negative), therapy such as medications, referrals or consults, and patient education. Nursing plans also add measurable goals and the findings that should trigger a call to the provider.

A quick check: every Plan item should trace back to a problem in your Assessment, and every problem should have at least one Plan item. If your instructor wants evidence cited for your interventions, format the references with this APA style guide.

Quick Sort: Subjective or Objective?

Cover the last two columns and decide where each finding goes.

SOAP Note Template for Nursing Students

Use this SOAP note template as a checklist while you write. Delete rows that do not apply to a focused visit, but keep the order.

If your program supplies its own form, such as this episodic/focused SOAP note template sample, follow its headings exactly, since your grader will compare your note against them.

SOAP Note Example: Med-Surg Patient with Pneumonia

This SOAP note example shows an RN-level note for a hospitalized adult. The patient is fictional and was created for teaching. The medication orders match the inpatient regimen in the ATS/IDSA community-acquired pneumonia guideline, and the nursing care follows the Open RN oxygenation chapter.

The Case

Patient A (fictional) is a 68-year-old man on hospital day 2 for community-acquired pneumonia in the right lower lobe. You are the student nurse on day shift.

The Note

S: Patient states, "I get winded just walking to the bathroom." Rates shortness of breath 2/10 at rest and 5/10 when walking. Reports a cough with thick yellow sputum since admission and sharp right-sided chest pain only when coughing, 4/10. Slept "maybe four hours" because of coughing. Denies chest pressure, dizziness or calf pain. No known drug allergies. Current medications per MAR: ceftriaxone 1 g IV every 24 hours; azithromycin 500 mg IV every 24 hours; acetaminophen 650 mg by mouth every 6 hours as needed for temperature above 38.0 °C.

O: 0800 vital signs: T 38.2 °C (100.8 °F) oral, HR 104, RR 24, BP 128/76, SpO2 93% on 2 L/min nasal cannula at rest (order: titrate oxygen to SpO2 94% to 98%). Alert and oriented to person, place, time and situation. Coarse crackles and diminished breath sounds in the right lower lobe; left lung clear. Productive cough with moderate thick yellow sputum. Walked 15 feet to the bathroom with standby assist; SpO2 fell to 89% and RR rose to 30, returning to 93% after 2 minutes of rest. Incentive spirometer best volume 750 mL. Oral intake 360 mL since 0700. WBC 14,600/mm³, down from 16,100/mm³ on admission. Admission chest X-ray: right lower lobe consolidation. Sputum culture pending.

A: 1. Ineffective airway clearance related to excessive mucus as evidenced by coarse crackles and diminished breath sounds in the right lower lobe and a productive cough with thick yellow sputum. 2. Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by exertional dyspnea of 5/10 and SpO2 falling to 89% with walking. Still febrile and tachycardic on hospital day 2, although WBC is trending down. Resting SpO2 is below the ordered target.

P: Increase oxygen per titration order and recheck SpO2 in 10 minutes. Keep the head of the bed in high Fowler's position. Coach incentive spirometer use 10 times every hour while awake and record volumes. Encourage oral fluids to thin secretions (no fluid restriction ordered). Give acetaminophen per PRN order and recheck temperature per unit policy. Give antibiotics on schedule. Plan rest before activity; walk with standby assist and portable pulse oximetry, stopping to rest if SpO2 drops below target. Reassess SpO2, RR and lung sounds every 4 hours and after activity. Notify the provider if SpO2 stays below target after titration, RR exceeds 28 (this unit's call parameter) or new confusion or restlessness appears. Goal: SpO2 94% or higher at rest and exertional dyspnea 3/10 or lower by discharge.

If your program uses SOAPIE, add what you did and how the patient responded:

I: 0815 oxygen increased to 3 L/min per titration order. Head of bed raised to high Fowler's. 0830 acetaminophen 650 mg by mouth given. Incentive spirometer coached at 0900 and 1000.

E: 0825 SpO2 96% on 3 L/min at rest. 0930 T 37.6 °C. 1000 best incentive spirometer volume 1,000 mL; crackles persist in the right lower lobe after patient coughed up moderate yellow sputum. Rates shortness of breath 2/10 at rest. Continue plan. [Date] 1030, [Student name], student nurse.

Why This Note Works

• Every diagnosis has evidence. Each nursing diagnosis names cues that appear in S or O, and Open RN says that clear link is what validates a nursing diagnosis.
• It shows a trend. The falling WBC, the persistent fever and SpO2 at rest versus activity tell the next nurse whether the patient is better or worse.
• The plan has numbers. Incentive spirometer frequency, an SpO2 target, reassessment timing and call triggers are all spelled out. The spirometer frequency and the 94% to 98% adult SpO2 target come from Open RN.
• Symptoms and signs are sorted. The patient's shortness of breath ratings sit in S; the crackles, oximetry and sputum you observed sit in O.

Focused SOAP Note Example for NP Students

NP clinical courses usually ask for a focused (episodic) note on a single problem. The example below is an outpatient visit with a fictional patient. Its exam and plan follow the Ottawa ankle rules and the American Academy of Family Physicians' 2025 review of acute ankle sprain management.

The Focused Note

S: CC: "I rolled my right ankle playing basketball yesterday." HPI: 24-year-old woman with right ankle pain for 1 day. Onset about 7 p.m. yesterday when she landed on another player's foot and the ankle turned inward. Pain on the outside of the ankle, constant, aching at rest and sharp with walking. Worse on stairs; better with rest and keeping the foot up. No radiation. Severity 3/10 at rest, 6/10 walking. Walked off the court with a limp. Took ibuprofen 200 mg by mouth once last night with partial relief. Denies numbness, tingling, knee pain or a "pop" at the time of injury. One prior right ankle sprain 3 years ago. Medical history: none. Daily medications: none. Allergies: no known drug allergies. Social: college student, plays intramural basketball, no tobacco use.

O: BP 118/72, HR 76, RR 14, T 36.8 °C. Antalgic gait; walked more than four steps unassisted in clinic. Right ankle: moderate swelling and bruising over the lateral ankle; tenderness anterior and inferior to the lateral malleolus. No bone tenderness at the posterior edge or tip of either malleolus, the navicular or the base of the fifth metatarsal. Squeeze test negative. Thompson test negative. Anterior drawer limited by pain and guarding. Dorsalis pedis and posterior tibial pulses 2+, capillary refill under 2 seconds, sensation intact. Left ankle normal.

A: Right lateral ankle sprain, inversion mechanism; grade not yet determined. Differential: (1) Ankle fracture, less likely: Ottawa ankle rules negative, since she bore weight immediately and in clinic and has no malleolar bone tenderness. (2) Fifth metatarsal base or navicular fracture, less likely: no midfoot bone tenderness. (3) High ankle (syndesmotic) sprain, less likely: negative squeeze test. (4) Achilles tendon rupture, unlikely: negative Thompson test.

P: No radiographs today per Ottawa ankle rules. Lace-up or semirigid ankle brace; limit immobilization to 5 to 10 days, then begin early functional activity. Ibuprofen 400 mg by mouth every 6 hours as needed for pain; acetaminophen is an alternative if she cannot take NSAIDs. Home exercises for range of motion and balance; refer to physical therapy for a neuromuscular rehabilitation program. Education: wear the brace for sports for up to 12 months to lower the risk of another sprain; return sooner for inability to bear weight, new numbness or color change in the foot. Follow-up in 5 to 7 days to reassess ligament stability. If pain persists, obtain radiographs, then MRI if radiographs are negative.

How the Differential Shapes the Plan

Every line of this Plan answers something in the Assessment. The negative Ottawa ankle rules justify skipping an X-ray today. Those rules come from emergency department research led by Ian Stiell, and they call for ankle radiographs only when there is pain near the malleoli plus bone tenderness at the posterior edge or tip of either malleolus, or an inability to bear weight (four steps) both right after the injury and at the visit. A pooled analysis summarized in American Family Physician found the rules about 97.6% sensitive for ankle and midfoot fractures.

The undetermined grade explains the 5 to 7 day recheck, because the 2025 AAFP review notes that the ligament exam is more accurate 4 to 7 days after injury. The brace, the short immobilization, the rehabilitation referral and the 12-month sports brace advice also come from that review, which found acetaminophen, NSAIDs and opioids similarly effective for pain.

When you write your own focused note, use the same pattern: name the most likely diagnosis, rule the alternatives in or out with specific findings, and make sure the Plan says what you will do if you are wrong.

How to Write a SOAP Note in 7 Steps

Write a SOAP note by gathering data in the same order the note is read, then building your conclusions from that data. These seven steps work for RN and NP notes alike.

1. Review the chart before you see the patient. Read the history and physical, provider orders, the MAR, recent labs and the last few progress notes so you know the baseline you are comparing against.
2. Interview for the chief concern and HPI. Start with open-ended questions, then fill the gaps with OLDCARTS. Quote the patient's words for the chief concern and for anything that may matter later.
3. Examine and measure. Take vital signs and do a focused exam of the systems linked to the concern. If a vital sign is out of range, recheck it and, as Open RN's Nursing Skills text advises students, tell your instructor or the patient's nurse right away.
4. Sort your findings. Symptoms go in S; signs, numbers and results go in O. Leave out anything that does not bear on the problem.
5. Cluster cues and name the problems. Group related findings, then write a nursing diagnosis statement or a diagnosis with a differential. Put the most urgent problem first.
6. Write a plan for each problem. Include actions, frequency, goals, education, follow-up and when to escalate.
7. Reread before you sign. Cut repeated data, replace risky abbreviations, confirm every plan item ties to a problem, and add the date, time and your signature, which Open RN lists as required for all documentation.

Document as soon as you can after the encounter, and never chart a task before you have done it, as Open RN warns. The same steps work for virtual patients, so documenting a Shadow Health assessment follows the same subjective-then-objective logic.

Weak vs Strong SOAP Note Entries

Most lost points come from entries that are vague, misplaced or unsafe. Here is how to fix the common ones.

The Joint Commission created its "Do Not Use" list in 2004. The minimum list covers U or u (unit), IU, Q.D./QD/q.d./qd, Q.O.D./QOD/q.o.d./qod, a trailing zero (X.0 mg), a missing leading zero (.X mg), and MS, MSO4 and MgSO4. It applies to orders, preprinted forms and medication-related documentation, whether handwritten or electronic. Write "unit," "daily," "every other day," "morphine sulfate" and "magnesium sulfate" in full, and write "0.5 mg," never ".5 mg." Open RN goes further and advises avoiding abbreviations in legal documentation, so check your program's approved list before you use any.

SOAP vs SOAPIE, APSO, DAR and Narrative Notes

SOAP is one of several documentation formats, and your clinical site may use a different one.

StatPearls points out two limits of classic SOAP. First, the assessment and plan sit at the bottom; one study it cites found the APSO order beat SOAP on speed, task success, accuracy and usability for clinicians looking up information from a primary care chronic disease visit. Second, SOAP does not build in time, so extended versions add an evaluation step, which is the job of SOAPIE's Evaluation line.

Privacy Rules for Student SOAP Notes

Never put information that identifies a real patient into a SOAP note you submit for a class. HIPAA's Safe Harbor de-identification standard at 45 CFR 164.514(b)(2) makes a useful checklist. It lists 18 types of identifiers that must be removed, including:

• names, including those of relatives, employers and household members;
• every part of a date except the year for dates tied to the patient, such as birth, admission and discharge dates;
• ages over 89, which may be grouped as "90 or older";
• street addresses, cities, counties and ZIP codes (only the first three digits may stay, and only for areas of more than 20,000 people);
• phone and fax numbers, email addresses, Social Security numbers and medical record numbers;
• full-face photos and any other unique identifying number, characteristic or code.

In practice, call the patient "Patient A," describe time as "hospital day 2" rather than a calendar date, and leave out the room number and any unusual detail, such as a rare occupation, that could point to one person. Your program's policy may be stricter than this list, so follow it first.

Using Examples Without Crossing the Line

The examples on this page show the format. Your graded note has to come from your own patient and your own reasoning, because a sample's assessment or plan copied onto a different patient will not match your data.

If you get stuck, ask for help with your own draft. Our nursing homework help tutors can explain clinical reasoning step by step, and you can ask a tutor to review a SOAP note you wrote and show you where your assessment and plan disconnect. That kind of feedback builds the skill your clinical instructor is grading.

Frequently Asked Questions

What Are the 4 Parts of a SOAP Note?

The four parts are Subjective, Objective, Assessment and Plan. Subjective holds what the patient or family reports, such as the chief concern, history and symptoms. Objective holds what you measure or observe, including vital signs, exam findings and test results. Assessment interprets that data as a prioritized problem list or diagnosis, and Plan lists the tests, treatments, nursing actions, education and follow-up for each problem.

How Long Should a SOAP Note Be?

There is no universal length. A focused note on one problem may fit on a single page, while a comprehensive admission note runs longer. StatPearls stresses that a succinct but thorough note is easier for other clinicians to review and use, so include what supports your assessment and plan and cut the rest. If your course sets a page or word limit, follow that limit.

What Is the Difference Between a SOAP Note and a Nursing Care Plan?

A SOAP note documents one encounter: what you found, what it means and what happens next. A nursing care plan is the ongoing plan for the patient's stay, with nursing diagnoses, goals, interventions, rationales and evaluation. The two overlap in the Assessment and Plan sections, and findings from a SOAP note often lead to care plan updates, but the care plan usually carries more detail on rationales and outcomes.

Do Nurses Write SOAP or SOAPIE Notes?

Both, depending on the facility and the program. Open RN's Nursing Fundamentals textbook describes SOAPIE as a progress note written by nurses and other health care team members, adding Interventions and Evaluation to the four SOAP sections. Many hospitals use other formats as well, such as focused DAR notes with charting by exception, so learn the format your clinical site uses before your first shift.

Where Do Medications and Allergies Go in a SOAP Note?

Either section works. StatPearls notes that current medications and allergies may be listed under Subjective or Objective. Completeness matters more than placement: each medication needs its name, dose, route and frequency, and each allergy should name the reaction. If the patient reports taking something that is not on the medication list, document it in Subjective and point out the discrepancy.

Can I Use Abbreviations in a SOAP Note?

Use only the abbreviations your facility or program approves, and never those on The Joint Commission's Do Not Use list, such as qd, qod, U, IU, MS, MSO4 and MgSO4, or trailing zeros and missing leading zeros. Open RN advises avoiding abbreviations in legal documentation. When in doubt, spell it out: "daily" and "units" take only a few more letters than the risky versions.

Can I Use a Real Patient for My SOAP Note Assignment?

Usually, yes. Most clinical SOAP note assignments are based on patients you cared for, but the note must be de-identified. Remove names, dates other than the year, record numbers, contact details, locations smaller than a state and any unique detail that could identify the person. Use a label such as "Patient A" and relative time such as "hospital day 2," and follow any stricter rules your program sets.