How to Write a SOAP Note in Nursing: Format, Examples & Common Errors

What Is a SOAP Note?

A SOAP note is a structured clinical documentation format used by nurses, nurse practitioners, physicians, and other healthcare providers to record patient encounters. SOAP stands for Subjective, Objective, Assessment, Plan. The format creates a logical, consistent record of clinical reasoning — moving from what the patient reports, to what you observe, to what you conclude, to what you will do.

In academic programs, particularly for advanced practice nursing (NP) students, SOAP note assignments assess your ability to collect, organize, and interpret clinical data and to develop a clinical management plan grounded in evidence. A well-written SOAP note is a demonstration of clinical reasoning compressed into a structured document.

The Four Sections Explained

S — Subjective

What the patient tells you

Chief complaint (CC) in the patient's own words. History of present illness (HPI) using OLDCART or OPQRST. Review of systems (ROS) — pertinent positives and negatives. Relevant PMH, PSH, medications (with doses), allergies, family history, social history. Written in narrative prose, attributing statements to the patient: "Patient reports…"

O — Objective

What you observe, measure, and find

Vital signs with full values. Physical exam findings organized by system (general appearance → HEENT → cardiovascular → pulmonary → abdomen → extremities → neurological). Diagnostic results: labs, imaging, ECG, point-of-care testing. Only measurable, observable data — no interpretation here.

A — Assessment

Your clinical interpretation

Primary diagnosis (with ICD-10 code for clinical settings). Differential diagnoses with brief reasoning. Analysis of how subjective and objective data support each diagnosis. This is the highest-level clinical reasoning section — where pathophysiology, evidence, and clinical judgment converge.

P — Plan

What you will do about it

Diagnostic orders (labs, imaging ordered or pending). Pharmacological management (medication name, dose, route, frequency, duration, rationale). Non-pharmacological interventions. Patient education provided. Referrals and consultations. Follow-up plan with specific timeframe. Disposition (discharge, admit, observe).

Writing a Complete HPI: OLDCART

The HPI is the most critical component of the Subjective section. Use OLDCART to ensure completeness:

Element	Question	Example
O — Onset	When did it start?	"Began 3 days ago upon waking"
L — Location	Where is it?	"Right lower quadrant, periumbilical initially"
D — Duration	How long does it last?	"Constant since onset; no relief periods"
C — Character	What does it feel like?	"Sharp, stabbing; patient guarding abdomen"
A — Aggravating	What makes it worse?	"Movement, deep breathing, eating"
R — Relieving	What makes it better?	"Lying still; partially improved with ibuprofen"
T — Treatment	What have you tried?	"Ibuprofen 400 mg twice; no improvement"

Complete SOAP Note Example: Community-Acquired Pneumonia

Subjective

CC: "I've had a cough with thick yellow-green sputum and fever for five days." HPI: Ms. R.K. is a 45-year-old female presenting with productive cough with yellow-green sputum, fever, and pleuritic right-sided chest pain for 5 days. Onset was gradual after URI symptoms 1 week prior. Fever measured at home: 38.9°C. Cough is productive, worsens with deep breath. Chest pain is right-sided, sharp, 6/10, worse with inspiration. Denies hemoptysis, significant dyspnea at rest, recent hospitalization, or antibiotic use in past 3 months. No recent travel or known TB exposure. PMH: Type 2 diabetes mellitus (diagnosed 2019); hypertension. PSH: Appendectomy 2010. Medications: Metformin 1000 mg BID, Lisinopril 10 mg daily. Allergies: Penicillin (rash). Social: Non-smoker; 1–2 alcoholic drinks/week; works as an elementary school teacher. Flu vaccine current; pneumococcal vaccine not on record. ROS: (+) cough, fever, chills, right pleuritic chest pain, mild dyspnea on exertion, fatigue. (-) hemoptysis, night sweats, weight loss, sore throat, rhinorrhea, nausea, vomiting, diarrhea.

Objective

Vitals: T 38.7°C | HR 102 bpm | RR 22 breaths/min | BP 128/82 mmHg | SpO₂ 94% on room air | Wt: 72 kg General: Alert, awake, appears moderately ill; mild respiratory distress; speaks in full sentences. HEENT: Oropharynx mildly erythematous; no exudates. TMs clear bilaterally. Neck: No lymphadenopathy. No JVD. Respiratory: Decreased breath sounds right lower lobe; dullness to percussion right base; egophony present right base; no wheezing; RR 22. Cardiovascular: Regular rate and rhythm; no murmurs. No peripheral edema. Abdomen: Soft, non-tender, non-distended; bowel sounds present. Extremities: No clubbing, cyanosis; capillary refill <2 sec. Neuro: Alert and oriented ×4; no focal deficits. Labs (point-of-care + ordered): WBC: 14.2 × 10⁹/L (elevated) | Segs: 82% | Bands: 8% BMP: Na 136 | K 4.0 | BUN 18 | Cr 0.9 | Glucose 148 CRP: 84 mg/L (elevated) | Procalcitonin: 1.8 ng/mL (elevated) CXR (portable): Right lower lobe consolidation with air bronchograms; no pleural effusion; no pneumothorax.

Assessment

1. Community-Acquired Pneumonia (CAP), right lower lobe — J18.9 Moderate severity. PSI/PORT Risk Class III. CURB-65 score: 1 (tachypnea). Supporting: productive cough, fever, pleuritic chest pain, RLL consolidation on CXR, elevated WBC with left shift, elevated CRP and procalcitonin, decreased breath sounds with egophony RLL. 2. Type 2 Diabetes Mellitus — elevated admission glucose; monitor closely; CAP in diabetic patients associated with higher complication risk. 3. Rule out: Pulmonary embolism (tachycardia, dyspnea, pleuritic pain) — Wells score 0; CXR consolidation more consistent with pneumonia; low pre-test probability.

Plan

Diagnostics: - Blood cultures ×2 before antibiotic administration - Sputum culture and Gram stain - Urine Legionella antigen; urine Streptococcus pneumoniae antigen - Repeat BMP in 24h (monitor glucose and renal function) - D-dimer if clinical suspicion for PE increases Medications: - Azithromycin 500 mg PO daily × 5 days (penicillin allergy; covers atypicals) + Ceftriaxone 1g IV q24h × 3–5 days (IDSA/ATS CAP guidelines for outpatient/moderate severity) - Acetaminophen 650 mg PO q6h PRN for fever and pain (preferred over NSAIDs with T2DM) - Supplemental O₂ via nasal cannula to maintain SpO₂ ≥ 94% - IV hydration: NS 125 mL/hr; reassess in 4 hours Non-pharmacological: Incentive spirometry q2h while awake; head of bed elevation 45°; encourage oral fluids; glycemic monitoring q4h Education: Importance of completing full antibiotic course; return precautions (worsening dyspnea, confusion, hemoptysis, SpO₂ <90%); pneumococcal vaccine when recovered; flu vaccine annually Disposition: Admit to medical unit. Reassess for step-down to PO antibiotics in 48–72h if improving (HR <100, T <38°C, SpO₂ ≥94% on room air, tolerating oral intake). Follow-up: Primary care in 6 weeks for repeat CXR to confirm resolution.

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Special Rules for NP SOAP Notes

SOAP notes for advanced practice nursing (NP) programs have higher clinical depth expectations than undergraduate nursing notes:

Include ICD-10 codes for all diagnoses in the Assessment section
Differential diagnoses must be listed with clinical reasoning — not just named
Pharmacological plan must include medication name, dose, route, frequency, duration, and rationale
Plan must address each diagnosis separately (numbered to match Assessment)
Patient education section must be specific: what was taught, in what language, using what method, and whether patient verbalized understanding

Common SOAP Note Errors

Error	Incorrect	Correct
Interpretation in Objective	O: "Patient appears anxious about diagnosis"	O: "Patient sitting with arms crossed; voice trembling; asked repeated questions about diagnosis." (A: Anxiety — goes in Assessment)
Vague HPI	"Patient has had abdominal pain for a few days"	"Patient reports periumbilical pain, 7/10, sharp, onset 3 days ago, constant, worsening with movement, radiating to RLQ"
Incomplete vitals	"Vitals stable"	List all values: T, HR, RR, BP, SpO₂, weight
Plan not matching Assessment	Assessment lists 3 diagnoses; Plan addresses only 1	Number Plan items to match Assessment diagnoses 1:1
Missing drug rationale	"Amoxicillin 500 mg PO TID × 10 days"	"Amoxicillin 500 mg PO TID × 10 days — first-line for streptococcal pharyngitis per IDSA guidelines (2021)"