What is a SOAP Note? [Subjective, Objective, Assessment and Plan Examples]

What is a SOAP Note?

SOAP notes are a clinical method used by healthcare practitioners to simplify and organize a patient’s information. Healthcare practitioners use the SOAP note format to record information in a consistent and structured way. (SOAP NOTE NURSING DEFINATION)

what is a soap note and how is it used

SOAP is an acronym that stands for subjective, objective, assessment, and plan. The elements of a SOAP note are:

SOAP Note Nursing Example

Subjective (S): 

Focused on the client’s information regarding their experience and perceptions of symptoms, needs, and progress toward treatment goals.

Subjective.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI (History of Present Illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Soap note Review of Systems example (ROS):

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

SOAP Note ROS Review of Systems Example 2

GENERAL:  no weight loss or gain, has fever, experiences chills, grandmother reports feeling warm on touch

HEENT:  Slight hearing loss, mild ear pain on the right ear, slight hearing loss, No sneezing, congestion, runny nose or sore throat. Eyes:  No visual loss, blurred vision

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No Burning on urination.

NEUROLOGICAL:  headache, No dizziness, syncope, paralysis, ataxia

MUSCULOSKELETAL:  No back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: Prominent tan, denies sweating

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

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References

Objective (O)

: Includes observable, objective data (“facts”) regarding the client, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.

Soap note Objective Example 1

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

Soap note objective nursing Example 2

O.

Physical exam

VS: Temp-97.6, BP-100/67, HR-73, RR-22, O2 sat-100%, Height-4’13.5” (91stpercentile), Weight-78lbs (59thpercentile), BMI-16.7 (24thpercentile);

General Appearance: healthy-appearing, well-nourished, and well-developed

Cardiovascular– S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs Carotid Arteries: normal pulses bilaterally, no bruits present.

Respiratory- Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi

Gastrointestinal– No rigidity or guarding, no masses present,

Pulmonary—No difficulty in breathing or dyspnea

Diagnostic Tests

    • Demonstration of osseous erosion on CT scanning

Soap note objective Example 3:

OBJECTIVE DATA:

            Physical Exam:

Vital signs: Vital Signs: Pulse 83 and regular Temp. 99F Resp. B/P 1st 120/72

Pulse Ox 98%, T 98.3 Orally; RR 16; non-labored; Wt: 165 lbs; Ht: 5’3; BMI 29.5

General: NAD, well-groomed

HEENT: No changes in vision or hearing. No history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She has had no recent ear infections, drainage or pain.

She does have a history recent sinus infection. She denies loss of taste, no difficulty in chewing and no swallowing and tooth/ gum pain or bleeding.

Neck: No pain on the neck, no injury or history of disc disease

Chest/Lungs: No chest pain

Heart/Peripheral Vascular: SOB, S1 and S2 audible, no murmur, gallops, heaves, or thrills. PMI at 4-5th ICS, MCL.

Abdomen: Bowel sounds present in all four quadrants, No masses palpated.

No lesions observed

Genital/Rectal: no cervical motion tenderness, no adnexal masses.

Musculoskeletal: age related atrophy; muscle strengths 5/5 all groups.

Neurological: Alert and oriented to person, place, and time. CN II-X intact.

Skin: rashes on right arm, no radiation of rash at this time, no itching, no acne,

 History of moles on left fingers

LAB/DIAGNOSTIC TESTS/EKG: No diagnostic studies performed.

Clinical appearance is sufficient for distinctive diagnosis.

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Assessment (A):

Includes the clinician’s assessment of the available subjective and objective information. The assessment summarizes the client’s status and progress toward treatment plan goals.

Here are three examples of SOAP NOTE ASSESSMENT section

Soap note Assessment Example 1:

ASSESSMENT:

Differential Diagnoses

    1. Otitis externa (Confirmed)
      1. Associated with recent water exposure. The skin of the outer ear becomes erythematous, swollen, tender, and warm, leading to debris and discharge accumulation. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. Narrow external auditory canal with purulent discharge (Wiegand et al., 2019). PT meets this diagnosis criteria.
    2. Otitis media with perforation (Refuted)
      1. Clear discharge or bloody followed by relief of pain, with an inflamed tympanic membrane with perforation in the middle ear. Associated with ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. Inflammation in external part of the ear canal thus refuting this diagnosis (Pontefract et al., 2019).
    3. Eustachian catarrh (Refuted)
      1. Occurs in the middle ear, and results after an upper respiratory infection (Vasudevan & David, 2016). Patient has a no recent upper respiratory tract infection. Refuted
    4. Ramsay Hunt syndrome (Refuted)
      1. Complication of shingles. May present with symptoms of otitis externa, yet has evidence of vesicular eruptions within 2 days of first onset of pain. Pt has no history of shingles, Refuted (Musso & Crews, 2016).
    5. Contact dermatitis (Refuted)
      1. Allergic reaction to materials (e.g., metals, soaps, plastics) in contact with the skin/epithelium; itching is predominant (Schaefer, & Baugh, 2012). Pt has no piercing or known allergic reactions, refuted.

Soap note Assessment nursing Example 2:

Assessment:

Differential Diagnosis:

    1. Herpes Zoster Virus (ICD-9: 053). Rash, pain and eruption of grouped vesicles in the same dermatome and fellow a segment of the body suggests herpes zoster virus. The symptoms described by ABC suggests Herpes Zoster Virus (Dains, Baumann, & Scheibel, 2019)
    2. Herpes Simplex Virus (ICD-9: 054). Prodrome, which can include symptoms, such as fever, malaise, loss of appetite, and localized pain and/or burning at the site the lesions will occur. Tingling and burning without lesions, to recurrent genital ulcerations. Typical widespread lesions clustered together and predilection for lips and genitalia (Dains, Baumann, & Scheibel, 2019). The rash ABC exhibits is not in the area and is on the same dermatome and is likely to be HSV (Kennedy, & Gershon, 2018).
    3. Contact Dermatitis (ICD-9: 692). Localized burning, stinging, itching, blistering, redness, and swelling at the area of contact with the allergen or irritant. ABC was not exposed to an allergen or environmental irritant and does not describe the rash as pruritic (Ball et al., 2019). Soap note nursing example

ASSESSMENT: Herpes Zoster Virus (ICD-9: 053).

Soap note Assessment nursing Example 3

ASSESSMENT:

Differential Diagnoses

    1. Hypertension Stage 3 or hypertensive crisis (Confirmed) With a BP of This in and of itself indicates a hypertensive crisis (Pierin et al, 2019). It calls for immediate attention by a physician and therefore the patient has to be admitted. A diastolic value of 107 mmHg is better than the systolic value meaning the physician could classify it has hypertension Stage 2 but since the readings are different (one better and one worse the classification is correct to the one considered worse.
    2. Hypertensive emergency (Refuted) unlike hypertensive urgency which has no associated target organ damage, the patient does not exhibit neurologic, aortic, cardiac, renal, and hematologic damage.
    3. Secondary hypertension due to another underlying medical condition or drug abuse(Refuted) the patient does not report to have any chronic condition other that spinal stenosis that was diagnosed 6 six years ago. It is hypertension that causes chronic neck pain like the one of spondylosis. Neither does the patient report of having any drug or substance issues.

Therefore the patient cannot take part in the study as his assessment points towards Chronic, unregulated hypertension is diagnosed: specifically hypertension urgency

Plan (P):

Records the actions to be taken due to the clinician’s assessment of the member’s current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.

Below is a breakdown of what you’ll require for the SOAP Note Plan section

Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

Here are three examples of the SOAP Note Plan Section

Soap note plan Example 1

P.

Plan (P):

Hypertension urgency. Promptly admit the patient for urgent hospital treatment and [pharmacologically manage the hypertension crisis. The physician further determines the type of hypertension crisis and determine that it is hypertensive urgency since there is no end organ damage (Alley & Schick, 2019). Most importantly, one should remember that if a hypertension crisis is not sufficiently treated aggressively, it can progress to hypertensive urgency where there is risk of death,

Therapeutics

A more specific and comprehensive cardiac assessment will ensue that comprises of a physical exam, taking the blood pressure of each arm , listening to heart and lung sounds, renal arteries , neurological exam and a funduscopic assessment (Somand, 2020). These are followed by a comprehensive laboratory checkup and should the patient be found to have unbalanced pulses in the palms imaging studies will be required. The patient will also require oral and intravenous medications like diuretics and antihypertensive (for example hydralaxzine, nitrates and alpha beta blockers amongst others) to lower and maintain the patients’ blood pressure

Patient Education

Research studies had demonstrated the efficacy of patient education in helping the hypertensive patient to contain and maintain their blood pressure at comparatively lower levels. The patient needs to educate on medications used to treat and manage HTN and the need to adhere to the dosage without skipping the prescribed medication. The patient is also made aware of how to self-monitor their BP and self- care at home. Non pharmacological interventions like regular exercises, taking a HTN friendly diet and cessation of smoking are some of the lifestyle modification the patient has to comply with for a healthy and quality life. Sticking to the recommended diet and regular exercise will also have the benefit of checking unnecessary weight gain (Somand, 2020).

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Consultation /Collaboration

Once, the clinician is done with the patient, a referral can be made so that the patient can have a complete assessment conducted a consultant physician/ specialist like a cardiologist for close monitoring of the BP and medication efficacy as well as the levels of serum creatinine and potassium at least  twice a year.

Soap note plan nursing Example 2:

Further diagnostic testing: No further diagnostic test needed

Medication:

    • Continue with Metformin 250 mg PO BID and Lisinopril 10 mg PO QD for his T2DM and HTN.
    • Administer
      • Aripiprazole 30 mg PO BID x14 days: Aripiprazole is an antipsychotic drug that affects multiple receptors, acting as a partial agonist at dopamine and serotonin 1A receptors, and an antagonist at serotonin 2A, α1 adrenergic, and other receptors. The medication has been found effective in calming dementia symptoms (Karlsson et al., 2017).
      • Administer Galantamine 4mg PO Q8 hrs x10 days: The medication works by restoring the balance of neurotransmitters in the brain. It has been effective in enhancing memory and the ability to carry out daily functions, besides treating mild to moderate confusion (Koola & Parsaik, 2018).

Patient Education:

Educate patient to:

    • Ensure compliance to the treatment regimen to achieve positive patient outcomes.
    • To increase the regularity of exercise to promote sleep
    • Ensure intake of a balanced diet with a variety of foods, including fruits, vegetables, low-fat dairy products, whole grains, and lean proteins to promote healing
    • Limit foods with high cholesterol and saturated fats to enhance his health Referrals: Refer the patient for one rehabilitation to ensure that dementia symptoms are addressed. If symptoms do not improve after 7 days of treatment, refer the patient to a geriatrician for additional evaluation.

Follow-up: F/u set in 7 days

Lastly: What does soap note stands for

The core things in a SOAP note include patient information, S- Subjective, O- Objective, A- Assessment and finally P- Plan.

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