How to Write a SOAP Note: Best Step-by-Step Guide for Nursing Students 2025

Learning how to write a SOAP note is essential for nursing students and healthcare professionals. The SOAP framework is the gold standard for systematically documenting patient encounters, formulating clinical assessments, establishing diagnoses, and developing actionable care plans with clarity and precision.

📋 Summary

• The SOAP note format (Subjective, Objective, Assessment, and Plan) is a standardized method for clinicians to document, assess, diagnose, and track patient care plans across all healthcare settings.
• The Subjective section captures what the patient says about their symptoms, concerns, and medical history—essentially the patient’s story in their own words.
• The Objective section includes measurable physical findings from the encounter, such as vital signs, examination results, laboratory data, and the patient’s observed appearance and functional status.
• The Assessment section is where the clinician synthesizes insights from the Subjective and Objective sections to interpret the clinical situation, formulate diagnoses, and consider differential diagnoses.
• The Plan section outlines the treatment strategy for the patient, including medications, interventions, diagnostic tests, follow-up timing, patient education, and both short- and long-term care goals.
• Best practices include prompt documentation (within 24 hours), clear and concise language, adherence to HIPAA privacy guidelines, use of standard medical terminology, and avoidance of subjective opinions, assumptions, and clinically irrelevant details.

What is a SOAP Note?

A SOAP note is a standardized documentation format used by healthcare professionals to record patient encounters in a structured and organized manner. It originated in the late 1960s as part of Dr. Lawrence Weed’s problem-oriented medical record, which emphasized systematic note-taking to improve both clinical reasoning and continuity of care. Unlike free-text documentation, SOAP notes provide a consistent format that ensures all relevant information is captured in a logical flow, making it easier to track the patient’s condition and plan of care over time.

A SOAP note example typically follows the same sequence regardless of the clinical specialty, whether it is primary care, emergency medicine, nursing, or mental health. This structured format not only improves clarity but also reduces the risk of overlooking critical details, which is essential in fast-paced healthcare environments.

What does SOAP stand for?

The acronym SOAP represents the four structured components of clinical documentation: Subjective, Objective, Assessment, and Plan. Each section serves a unique purpose, ensuring that all aspects of a patient encounter are captured logically and systematically. This structured format allows healthcare providers to move from the patient’s perspective to measurable findings, followed by clinical reasoning, and finally to actionable next steps in the plan of care.

How to Write a SOAP Note

Learning how to streamline write a SOAP note requires more than just memorizing what each letter of the acronym means. It involves developing strategies for capturing relevant information, avoiding common pitfalls, and ensuring the documentation is both clinically useful and legally sound. Below is a detailed guide to writing each part of the SOAP note effectively, with practical techniques and examples to illustrate best practice.

1. Document the Subjective section

The subjective section relies heavily on communication skills, active listening, and careful organization of the patient’s story. Since this section reflects the patient’s condition from their perspective, it requires precision without interpretation.

Techniques for writing:

1. Start with the chief complaint. Document the main reason for the visit in the patient’s own words (e.g., “I have been coughing for a week”). This provides clarity and keeps the note concise.
2. Structure the history of present illness. Use frameworks such as OLDCARTS (Onset, Location, Duration, Character, Aggravating/Relieving factors, Timing, Severity) to gather a clear narrative. This ensures the subjective section includes details relevant to differential diagnoses.
3. Capture pertinent negatives. Including what the patient is experiencing, not having (e.g., no chest pain, no fever), refines the diagnostic process.
4. Include social and past medical context. A focused past medical history, social history, and current medications provide context without overwhelming the note.
5. Use the patient’s own words sparingly but accurately. Place short, impactful quotes in quotation marks for emphasis.

✍️ Writing the Subjective Section

Techniques for Accuracy:

1. Start with the chief complaint in the patient’s own words
2. Structure using OLDCARTS for the complete history
3. Capture pertinent negatives (what symptoms are absent)
4. Include focused context (PMH, social history)
5. Use direct quotes sparingly but accurately

Example:

“CC: ‘My knee has been swollen since I fell yesterday.’ HPI: 45-year-old reports pain localized to left knee, swelling began within 2 hours, worsens with weight-bearing, improves with rest. Denies locking, giving way, or fever. No significant PMH. Works as teacher, ambulates independently.”

❌ Avoid:

• Irrelevant life history details
• Provider interpretation
• Missing pertinent negatives
• Paraphrasing without quotes

Mini-example (Subjective):
“CC: ‘My knee has been swollen since I fell yesterday.’ HPI: 45-year-old client reports pain localized to the left knee, swelling began within 2 hours, worsens with weight-bearing, and improves with rest. Denies locking, giving way, or fever. No significant past medical history. Works as a teacher, ambulates independently.”

2. Formulate the Objective Section

The objective section provides verifiable objective findings from the exam, tests, or direct observation. Because it anchors the note in measurable evidence, accuracy is essential.

Strategies for ensuring accuracy:

1. Always record vital signs first. They give an immediate snapshot of the patient’s condition and can influence urgent decision-making.
2. Use a consistent format. Organize physical exam findings by system (e.g., cardiovascular, respiratory, musculoskeletal) for readability.
3. Be specific and measurable. Replace vague terms like “normal” with objective data (e.g., “Respiratory rate 20/min, clear breath sounds bilaterally”).
4. Document only what you observed today. Avoid assumptions or copying older data unless it is relevant to the current patient encounter.
5. Include diagnostic results concisely. Summarize significant lab values, imaging, or point-of-care tests instead of reproducing full reports.

📊 Writing the Objective Section

Strategies for Precision:

1. Record vital signs first with units
2. Use consistent format (organize by system)
3. Be specific and measurable (numbers > adjectives)
4. Document only today’s findings
5. Summarize diagnostics concisely

Example:

“BP: 142/90 mmHg, HR: 88 bpm, Temp: 37.6°C. Gait antalgic, left knee swollen, erythema absent. ROM limited to 70° flexion. No joint instability. X-ray: no fracture.”

❌ Avoid:

• Vague terms like “normal” or “WNL”
• Subjective impressions
• Copy-pasting old data
• Disorganized findings

Mini-example (Objective):
“BP: 142/90 mmHg, HR: 88 bpm, Temp: 37.6°C. Gait antalgic, left knee swollen, erythema absent. Range of motion limited to 70° flexion. No joint instability on exam. X-ray: no fracture.”

3. Conduct and Document your Assessment

The assessment section is where subjective and objective data converge into professional judgment. It demonstrates clinical reasoning and outlines possible diagnoses or problems.

🎯 Writing the Assessment Section

Best Practices:

1. State primary diagnosis first with supporting evidence
2. List differential diagnoses in descending likelihood
3. Link findings to rationale (connect S/O to conclusion)
4. Separate multiple problems using numbered lists
5. Acknowledge uncertainty explicitly

Example:

“1. Left knee injury—likely ligament sprain; swelling and limited ROM but no fracture on imaging. Differential: meniscal tear, gout (less likely without erythema). 2. Hypertension—elevated BP, requires monitoring.”

❌ Avoid:

• Listing symptoms instead of diagnoses
• Omitting differential diagnoses
• Failing to connect S/O data
• Vague clinical impressions

Best practices for assessment writing:

1. Prioritize the main problem. State the most likely diagnosis clearly, supported by evidence from the S/O sections.
2. List differential diagnoses. When uncertainty exists, document alternative possibilities and why they are more or less likely. This demonstrates critical thinking.
3. Link findings to rationale. Write a short justification that ties subjective and objective sections to your impression.
4. Separate problems clearly. If the patient has multiple issues (e.g., diabetes and knee pain), create a numbered list to avoid confusion.
5. Be honest about uncertainty. A good assessment does not guess—it explains what is known and what requires further evaluation.

Mini-example (Assessment):
“1. Left knee injury—likely ligament sprain; swelling and limited ROM but no fracture on imaging. Differential: meniscal tear, gout (less likely without erythema).
2. Hypertension—elevated BP, requires monitoring.”

4. Write the Plan Section

The plan section of a SOAP note converts clinical impressions into actionable steps. It ensures continuity, safety, and accountability in care delivery. An effective SOAP note must have a plan that is specific, realistic, and measurable.

Steps to writing the plan:

1. Divide the plan by problem. Each issue listed in the assessment should have its own corresponding plan of care.
2. Outline therapeutic measures. Document medications, procedures, and lifestyle recommendations. Specify dosages, frequency, and follow-up.
3. Add diagnostics and referrals. Note pending tests, referrals to other health professionals, or consultations.
4. Define monitoring and follow-up. State when the patient will be reviewed and what indicators (e.g., improvement in pain, stable vital signs) will be reassessed.
5. Document patient education and safety-netting. Describe what instructions were given, including red flags that should prompt urgent return.
6. Be concise but comprehensive. A well-written plan should guide any other provider who may continue care.

Mini-example (Plan):
“1. Knee sprain—apply ice packs, prescribe NSAIDs (ibuprofen 400 mg q8h for 5 days). Refer to physiotherapy for mobility exercises. Follow-up in 10 days or earlier if swelling worsens.
2. Hypertension—initiate DASH diet counseling, encourage home BP log, recheck in 2 weeks. Consider starting antihypertensive if persistently elevated.”

SOAP Note Format

A soap note turns a complex patient encounter into a logical narrative that supports safe, coordinated patient care. The four parts—S, O, A, and P—each answer a different clinical question and, together, create a defensible entry in the medical record. Below, each component is explained in depth, with practical inclusions and a brief mini-example to show how it reads in practice.

What is the Subjective section?

Purpose. The subjective section captures the patient’s story in their own words and context: why they sought care, how a problem began, and what matters to them. It anchors your note in the patient’s perspective, which you’ll later test against objective data. 

Include:

• Chief complaint (one line, in quotes when feasible).
• History of present illness (organized, e.g., OLDCARTS), linking symptoms to function.
• Focused past medical history, social history, and current medications when they directly inform today’s problem.
• Pertinent positives and negatives (what is present and notably absent).
• Patient goals, concerns, and barriers (e.g., cost, transport, caregiving).

Writing tips.

• Use the patient’s phrasing sparingly but accurately; avoid interpreting symptoms here.
• Be clear and concise; select relevant information that will matter downstream in the A/P.
• If using a proxy historian (a client’s caregiver), identify the source.

Mini-example (Subjective).
“CC: ‘Pressure in my chest when I walk.’ HPI: 2-day history of exertional chest pressure, 6/10, resolves with rest; no fever or cough. Denies leg swelling. Smokes ½ ppd. Father had MI at 52. Goal: ‘I want to know if it’s my heart.’”

What should be included in the Objective section?

Purpose. The objective section records measurable, observable facts gathered today—your exam, tests, and other objective findings that can be verified by any healthcare provider. 

Include:

• Vital signs (with units and context).
• Focused physical exam keyed to the complaint; note abnormal and key normal items.
• Point-of-care tests and laboratory/imaging summaries (with most decision-relevant values).
• Functional measures when applicable (e.g., gait, ROM, timed tests).
• Brief observational data (appearance, affect; or a focused mental status exam in behavioral health).

Writing tips.

• Prefer numbers over adjectives; mark trends when available.
• Record only what you observed/performed today; avoid duplicating older health records unless clinically necessary.
• If equipment or test quality limits interpretation, say so.

Mini-example (Objective).
“Afebrile; BP 150/92, HR 96, RR 22, SpO₂ 97% RA. Appears anxious, no respiratory distress. Cardiac: RRR, no murmurs. Lungs: clear. Calves: nontender, no edema. ECG in clinic: NSR, no ST-T changes.”

How do you formulate the Assessment section?

Purpose. The assessment section is your synthesis—where subjective and objective sections are integrated through clinical reasoning to define the problem(s) and level of risk. It states your working diagnosis and, when appropriate, your differential diagnoses. 

Include:

• The most likely condition first; add alternative diagnoses in descending likelihood.
• Rationale: one or two lines tying key S/O data to your impression.
• Status/severity (stable, worsening), complications, and uncertainties.
• If applicable, respond to initial therapy today.

Writing tips.

• Be problem-oriented; separate each issue (e.g., “Chest pain—suspected stable angina,” “Hypertension—suboptimally controlled”).
• Name uncertainty explicitly; it justifies testing and safety-netting.
• Keep the narrative tight; reserve details for S/O.

Mini-example (Assessment).
“1) Exertional chest pain—probable stable angina given exertional pattern, risk factors (tobacco, family history), and normal ECG at rest; ACS less likely without rest pain/ECG changes. 2) Stage-2 HTN—elevated BP today, needs confirmation.”

What is the purpose of the Plan section?

Purpose. The plan section converts your assessment into action—your treatment plan and next steps. It should be specific, time-bound, and measurable, showing exactly how you will monitor and modify care. Many disciplines pair the assessment and plan for each problem, and therapy disciplines explicitly link the plan to the “plan of care.” 

Include (by problem):

• Therapeutics: medications/procedures with dose, route, duration; patient education.
• Diagnostics: what you’re ordering now and why.
• Referrals/coordination: who you’re involving (e.g., cardiology, counseling).
• Monitoring & follow-up: concrete intervals, parameters, and warning signs.
• Safety-netting & consent: what to do if symptoms escalate; brief risks/benefits discussed.

Writing tips.

• Use bullets by problem; it keeps the section outlines readable and auditable.
• Align every action to the assessment rationale.
• Close loops (e.g., where results will be reviewed and communicated) to help you write defensible, coordinated notes to document care. 

Mini-example (Plan).
“1) Chest pain—begin trial of SL nitroglycerin PRN; start atorvastatin 40 mg nightly; schedule stress test within 72 h; cardiology referral; ED precautions reviewed (rest pain, dyspnea). F/U 1 week.
2) Hypertension—home BP log bid x 7 days; initiate amlodipine 5 mg daily; diet/exercise counseling; clinic BP recheck in 2 weeks.”

Frequently Asked Questions

What is an example of a SOAP note?

A patient presents with chest pain:

• S (Subjective): “I have had sharp chest pain for two hours, worsens with exertion.”
• O (Objective): BP 150/90, HR 110, ECG shows ST depression, troponin pending.
• A (Assessment): Suspected angina vs myocardial infarction.
• P (Plan): Admit for monitoring, give aspirin, order cardiac enzymes, cardiology consult.

How to properly write SOAP notes?

Use the four-part structure: record the patient’s story in Subjective, measurable findings in Objective, interpret the data in Assessment, and document next steps in Plan. Keep entries clear, concise, clinically relevant, and avoid unnecessary detail.

What is the format of SOAP?

SOAP is an acronym:

• S – Subjective (patient’s reported symptoms),
• O – Objective (observable or test results),
• A – Assessment (clinical impression/diagnosis),
• P – Plan (treatment and follow-up).

How long do SOAP notes take to write?

On average, SOAP notes take 5–10 minutes for a straightforward patient, though complex cases may require more time. With practice and templates, the process becomes quicker and more efficient.