What Are SOAP Notes in Nursing + Examples

Subjective

Subjective pertains to patient-reported information and symptoms as well as personal views or feelings. Other subjective data includes:

• The chief complaint
• History of present illness (HPI)
• History, review of systems (ROS)
• Current medications
• Allergies

Some healthcare providers will document current medications and allergies under the objective section, which is acceptable. Where providers document this information doesn't matter as long as they note the medication name, dose, route, and frequency.

Objective

Objective data includes signs, but NOT symptoms, related to the associated symptom reported by a specific patient. This is measurable and observable data collected during a particular patient encounter or hospitalization. Information in this section will include:

• Vital signs
• Physical exam findings
• Imaging results from MRI, CT Scans, X-rays
• Laboratory data
• Patient’s behavior and appearance
• Other diagnostic data

Assessment

Assessment documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. Elements of the assessment include the problem and differential diagnosis. The differential diagnosis includes most likely to least likely, and the reasoning behind the list.

Plan

In the plan section, a provider will note whether the patient needs additional testing or a consultation with other specialists. They will also include interventions and proposed treatment options in this section.

1. Collect Subjective Data

You can collect subjective data directly from the patient or their close family members. You should determine the patient's chief complaint, or what brought the patient to the hospital. Then, gather information about the patient's medical and surgical history and how it may be relevant to the chief complaint.

Because of the nature of nursing, you may obtain some of the subjective data you collect from the patient's chart. For example, medical providers will do a complete medical reconciliation and list allergies when they admit patients to the hospital. Chart data can be invaluable for writing SOAP notes because, depending on why the patient presented to the hospital, it may not be possible to gather some of the subjective data yourself.

2. Collect Objective Data

Next, collect any objective data, including vital signs, physical assessment findings, relevant test results, including diagnostic radiology imaging, and laboratory values. Some of this information will be from directly observing the patient, while other parts, such as test results, will come from reviewing the chart.

3. Assess Collected Data

After performing a complete, comprehensive physical assessment on the patient, utilize clinical judgement and synthesize all subjective and objective data.

4. Plan Treatment and Interventions

The final aspect of a SOAP note is the plan. Outline all possible treatment options, strategies, and interventions based on the subjective and objective data.

SOAP Note Example #1 - Pediatric PCP Sick Visit

Subjective

Patient is a 3-year-old male, whose mother reports that patient presents with significant ear pain. Patient was seen earlier this week for bilateral ear pain after swimming, normal Tms, tenderness of b/l pinnae and tragus. He was diagnosed with swimmer’s ear and treated with ofloxacin five drops daily for seven days. Course of medication not finished yet. 

Objective

Vital signs as noted below: 

• Pulse: 100
• Respirators: 24
• Temperature: 36.7 orally
• Pulse ox: 99%
• Weight: 34 lbs 4 oz
• Height: 3' 2.5"

PHYSICAL EXAMINATION

• GENERAL: alert, no acute distress
• HEAD: normocephalic, atraumatic
• EYES: no conjunctival injection, no discharge
• EARS: Right TM bulging, erythematous with purulent fluid, mild erythema in canal of right ear, left ear normal without erythema or swelling, left TM normal, no tenderness, erythema or swelling of the bilateral pinnae
• NOSE: clear rhinorrhea
• MOUTH/THROAT: moist mucosa, no oral lesions
• NECK: supple, full range of motion
• CHEST: clear to auscultation, good aeration to the bases, no wheezing, no crackles, no tachypnea, no retractions
• CARDIOVASCULAR: RRR, no murmur
• ABDOMEN: soft, non-tender, no organomegaly or masses, normal bowel sounds
• SKIN: no rashes
• LYMPH NODES: no cervical adenopathy

Patient has no recent labs or diagnostic imaging, no allergies, and no medications. 

Assessment

Based on the subjective and objective information, the patient meets the criteria for an inner ear infection. 

Plan

Recommended that the patient start an oral antibiotic and continue previous medication (ofloxacin) for the full seven-day course. Follow up in one week if symptoms do not improve. 

SOAP Note Example #2 - Adult Dermatology

Subjective

Adult male, age 40, reports a rash on back and arms for the last month. Patient reports rash worsens after swimming and showering, and it is itchy and painful at times. Patient reports being a runner and actively running every day outside. 

Objective

Vital signs as noted below: 

• Pulse: 74​​
• Respirators: 16
• Temperature: 36.7 orally
• Pulse ox: 99%
• Weight: 174 lbs 8 oz
• Height: 6' 4"

PHYSICAL EXAMINATION

• GENERAL: alert, no acute distress
• HEAD: normocephalic, atraumatic
• EYES: no conjunctival injection, no discharge
• EARS: no tenderness, erythema or swelling of the bilateral pinnae
• NOSE: no rhinorrhea
• MOUTH/THROAT: moist mucosa, no oral lesions
• NECK: supple, full range of motion
• CHEST: clear to auscultation, good aeration to the bases, no wheezing, no crackles, no tachypnea, no retractions
• CARDIOVASCULAR: RRR, no murmur
• ABDOMEN: soft, non-tender, no organomegaly or masses, normal bowel sounds
• SKIN: Erythematous, raised, and pruritic papules and patches on the patient’s back and arms. There is significant thickening of the skin. No evidence of crusting, oozing, or scaling.
• LYMPH NODES: no cervical adenopathy

Patient has no recent labs or diagnostic imaging. Patient is allergic to sulfa drugs and penicillin. Patient reports taking the following medications:

• Multivitamin, 1 pill, PO, daily 
• Sertraline, 25 mg, PO, daily
• Lisinopril, 20 mg, PO, daily

Assessment

Patient’s skin assessment is consistent with eczema, specifically an ongoing flare. 

Plan

Patient should take cool showers daily and immediately following working out. Utilize Dove Sensitive soap and pat areas dry versus  rubbing. Avoid scratching. Apply ​​triamcinolone ointment to affected areas nightly for five days. Follow up in one week.

SOAP Note Example #3 - Orthopedic Patient in ER

Subjective

Patient is a 45-year-old male who presents to the emergency room with right hip, shoulder, and ankle pain that began two days following a jet skiing accident. Patient states that he was with his friends on jet skis and lost control, resulting in him flying off the back of the jet ski. He reports sharp and burning pain between the clavicle and rotator cuff with swelling and bruising. Patient has been icing his shoulder and ankle. Wife reports patient taking Tylenol around the clock for the last two days since the accident. 

Patient reports overall pain of 8/10, but is unable to differentiate between the pain in different areas of his body. 

Objective

Vital signs as noted below: 

• Pulse: 104​​
• Respirators: 22
• Temperature: 37.3 orally
• Pulse ox: 96%
• Weight: 274 lbs 1 oz
• Height: 5' 8"

PHYSICAL EXAMINATION

• GENERAL: alert, patient reports of 8/10, unable to specify location
• HEAD: normocephalic, atraumatic
• EYES: no conjunctival injection, no discharge
• EARS: no tenderness, erythema, or swelling of the bilateral pinnae
• NOSE: no rhinorrhea
• MOUTH/THROAT: moist mucosa, no oral lesions
• NECK: supple, full range of motion
• CHEST: clear to auscultation, good aeration to the bases, no wheezing, no crackles, no tachypnea, no retractions
• CARDIOVASCULAR: RRR, no murmur
• ABDOMEN: soft, non-tender, no organomegaly or masses, normal bowel sounds
• SKIN: Scattered bruising noted throughout body. Right ankle swelling and bruising. Right shoulder with bruising and swelling. Limited ROM. 
• LYMPH NODES: no cervical adenopathy

Patient allergic to cephalosporins, antacids, mangos, and apples. 

Currently taking the following medications:

• Fluoxetine, 20 mg, PO, daily
• Multivitamin, 1 pill, PO, daily
• Tylenol, 650 mg, PO, every 4-6 hours as needed for pain
• Levothyroxine, 50 mcg, PO, daily
• Omeprazole, 40 mg, PO, daily

Assessment

Patient with dislocated clavicle, ankle sprain, and bruised hip. 

Plan

Administer pain medications as ordered, keep ankle elevated, and utilize ice. Patient to be admitted to the orthopedic floor once a bed becomes available.