SOAPIE Nursing Notes
SOAPIE extends SOAP with two more parts: Intervention (what was done) and Evaluation (how the patient responded).
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 ends at a plan. SOAPIE continues through what was actually carried out and whether it helped, which matches the full nursing process: assess, diagnose/interpret, plan, implement, evaluate. The extra sections make it harder to leave out the outcome.
When this may be used
- Problem-oriented nursing documentation where the full cycle of care is recorded in one entry.
- Some programs teach SOAPIE; some organizations use SOAPIER (adding Revision) or other variations.
- Follow the format your organization uses.
Components
Subjective
Reported information.
What belongs here
- Patient statements
What does not belong
- Observations
Objective
Observed or measured information.
What belongs here
- Vital signs, assessment findings
What does not belong
- Patient opinions
Assessment
Interpretation supported by S and O.
What belongs here
- Nursing judgment within role
What does not belong
- Unsupported conclusions
Plan
Intended actions.
What belongs here
- Planned nursing actions
What does not belong
- Invented orders
Intervention
Actions actually carried out.
What belongs here
- What you did, with times
What does not belong
- Plans not yet done
Evaluation
Outcome.
What belongs here
- Patient response, reassessment findings
What does not belong
- Assumed outcomes
Short fictional example
- Subjective
- Patient states "I'm freezing."
- Objective
- Temperature 36.4 °C oral. Skin cool to touch on arms.
- Assessment
- Patient reports feeling cold; temperature within the unit's reference range.
- Plan
- Provide warm blanket; recheck comfort.
- Intervention
- Warm blanket applied at 2010.
- Evaluation
- At 2040 patient states "much better, I'm warm now."
More detailed fictional example
- Subjective
- Patient states "I feel nauseated" and rates nausea 5/10. Denies vomiting.
- Objective
- No emesis observed. Ate 25% of clear liquid lunch. Abdomen soft.
- Assessment
- New nausea after clear liquid lunch.
- Plan
- Administer antiemetic as ordered PRN; reassess nausea in 30 minutes.
- Intervention
- 1250: Ondansetron 4 mg IV given per PRN order. Cool washcloth provided per patient request.
- Evaluation
- 1320: Patient rates nausea 1/10. No emesis.
Annotated example
Notes on the detailed example above:
rates nausea 5/10
— A patient-reported rating is subjective data, and it gives a baseline for evaluation.Plan: Administer antiemetic as ordered PRN
— The plan refers to an existing order in this fictional scenario; the note does not invent treatment.1250: Ondansetron 4 mg IV given per PRN order.
— Intervention records what was actually done and when.1320: Patient rates nausea 1/10.
— Evaluation compares with the baseline using the same scale.
Common mistakes
- Copying the Plan into Intervention without confirming it was done.
- Writing an Evaluation with no time or no comparison to the baseline.
- Skipping Evaluation because the patient "seemed fine."
Good vs poor documentation
Weaker (fictional)
E: Effective.
Stronger (fictional)
E: 1320: Patient rates nausea 1/10 (was 5/10 at 1245). No emesis.
Why: An evaluation should state what was reassessed and when.
Blank educational template
SOAPIE note: SOAP plus Intervention and Evaluation. Prompts only; nothing is prefilled.
- Subjective
- [What the patient or another source reports]
- Objective
- [Observed and measured findings]
- Assessment
- [Nursing interpretation supported by S and O]
- Plan
- [Planned actions and follow-up]
- Intervention
- [Actions actually performed]
- Evaluation
- [Patient response and reassessment findings]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- SOAP notes
- DAR notes
- Medication response
- Dosage Calculator — Practice the medication math behind a dose you document.
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.