SOAP Nursing Notes
SOAP is a problem-oriented format with four parts: Subjective, Objective, Assessment and Plan.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
SOAP separates what the patient reports from what you observe, then asks you to interpret those findings and plan next steps. The order forces the assessment to be built on evidence: a reader can check that every conclusion in A is supported by something in S or O.
When this may be used
- Problem-oriented records, where each note addresses a specific problem.
- Many settings use SOAP for provider notes; some nursing programs and facilities use it for nursing notes.
- Use and wording vary by organization and role.
Components
Subjective
What the patient or another source reports.
What belongs here
- Symptoms described by the patient
- Direct quotes
- Reports from family, labeled with the source
What does not belong
- Your observations
- Your interpretation
Objective
What can be observed or measured.
What belongs here
- Vital signs
- Physical assessment findings
- Measured intake/output
What does not belong
- Patient opinions
- Words like "appears to be in pain" without describing what you saw
Assessment
Nursing interpretation supported by S and O.
What belongs here
- A nursing judgment within your role, supported by findings
What does not belong
- A medical diagnosis outside your scope
- Conclusions with no supporting data
Plan
What will happen next.
What belongs here
- Planned nursing actions and follow-up consistent with orders and policy
What does not belong
- New medical orders you invented
- Care already completed described as planned
Short fictional example
- Subjective
- Patient states "I only slept about 2 hours; the hallway is loud."
- Objective
- Room door open to hallway. Patient yawning during conversation.
- Assessment
- Sleep disrupted, which the patient attributes to hallway noise.
- Plan
- Offer to close door and dim lights at bedtime; ask about sleep quality in the morning.
More detailed fictional example
- Subjective
- Patient states "I haven't had a bowel movement since before surgery" and "my belly feels full." Patient reports passing gas this morning.
- Objective
- Abdomen soft, mildly distended. Bowel sounds present in all four quadrants. Tolerated 100% of clear liquid breakfast. Walked in hallway twice this shift with assist of one.
- Assessment
- No bowel movement since surgery; patient reports fullness and is passing gas.
- Plan
- Continue to encourage walking. Monitor and document bowel movements. Report absence of bowel movement to provider per unit protocol.
Annotated example
Notes on the detailed example above:
"I haven't had a bowel movement since before surgery"
— Subjective: the patient's report, quoted.Bowel sounds present in all four quadrants
— Objective: an assessment finding the nurse actually obtained.No bowel movement since surgery; patient reports fullness…
— Assessment summarizes and connects S and O without a medical diagnosis.Report… per unit protocol
— The plan follows existing protocol rather than inventing treatment.
Common mistakes
- Placing measurements in Subjective or patient quotes in Objective.
- Writing an Assessment that has no supporting data in S or O.
- Writing a medical diagnosis the nurse cannot make.
- A Plan that invents orders.
Good vs poor documentation
Weaker (fictional)
O: Patient says belly feels full.
Stronger (fictional)
S: Patient states "my belly feels full." O: Abdomen soft, mildly distended.
Why: Patient reports are subjective; observations are objective.
Blank educational template
SOAP note: Problem-oriented: Subjective, Objective, Assessment, Plan. Prompts only; nothing is prefilled.
- Subjective
- [What the patient or another source reports, in their words where useful]
- Objective
- [Observed and measured findings]
- Assessment
- [Nursing interpretation supported by S and O, within your role]
- Plan
- [Planned nursing actions and follow-up, consistent with orders and policy]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.