SOAP notes turn up across nursing education, from clinical logs and simulation write-ups to case studies. They are also a format you will use in practice, especially at advanced practice level.
This guide explains what belongs in each of the four sections, where students most often blur them, and how to make the note read as one line of clinical reasoning. A full worked example shows how it fits together.
The Four Parts of a SOAP Note
A SOAP note records one clinical encounter in four parts: Subjective (what the patient reports), Objective (what you observe and measure), Assessment (your interpretation of both) and Plan (what happens next).
Keep data and interpretation apart, justify the assessment with specific findings, and make every plan item answer a problem named in the assessment.
What SOAP Stands for and Why the Order Matters
SOAP is more than a filing system. It mirrors how clinicians reason: start with the patient's account, add what you can observe and measure, decide what it means, then act.
Each section depends on the one before it. An assessment that cites no subjective or objective findings is a guess. A plan that ignores the problems in the assessment has lost the reasoning that should drive it.
Faculty usually grade both levels: whether each section holds the right kind of information, and whether the four sections build one coherent argument. That is the same chain of reasoning you use in a pathophysiology case study, compressed into a documentation format.
What Goes in Each Section
Use this table as a sorting tool while you draft. If a sentence fits the "does not contain" column of the section it sits in, move it.
| Section | Contains | Does not contain |
|---|---|---|
| Subjective (S) | Chief complaint, history of present illness, symptoms, relevant history, medications and allergies as reported by the patient | Vital signs, exam findings, results or anything you measured |
| Objective (O) | Vital signs, physical exam findings by system, lab and imaging results, observed behavior | Your interpretation, or the patient's description of symptoms |
| Assessment (A) | Diagnosis or differentials, clinical impression, problem list, with justification from S and O | New data, or a restatement of S and O with no interpretation |
| Plan (P) | Diagnostics, treatments, education, follow-up and referrals, organized by problem | Vague intentions with no what, how often or trigger for change |
Subjective: The Patient's Account
Start with the chief complaint, ideally in the patient's own words, such as "My chest has been hurting since yesterday". Then expand it into a history of present illness.
A mnemonic keeps the history complete. OLDCARTS covers onset, location, duration, characteristics, aggravating and alleviating factors, radiation, timing and severity. OPQRST is a common alternative for pain.
Add past medical history, medications, allergies and social history, but only the parts relevant to the current problem. A focused note does not need a life history.
Include pertinent negatives. Writing "denies shortness of breath at rest and haemoptysis" shows you screened for red flags, and it supports the differentials you rule out later.
Objective: Just the Data
Objective is where interpretation most often slips in. "Lungs sound congested" is a judgment; "bilateral crackles in the lower lung fields" is a finding.
A useful test is whether two clinicians examining the same patient would record the same thing. If the answer depends on your opinion, it belongs in the assessment.
List vital signs first, then exam findings by body system, then any results available at the time of the note. Use measurable terms and units throughout.
Assessment: Where Reasoning Happens
The assessment pulls the subjective and objective findings into a clinical picture. For a single problem, that may be one diagnosis with a short justification.
For a complex patient, use a numbered problem list and give each problem its own brief assessment. Most rubrics expect you to point back to specific findings rather than just naming a diagnosis.
Weak: "Acute bronchitis."
Strong: "Acute bronchitis, supported by a five-day productive cough (S) and bilateral rhonchi with a temperature of 100.4°F (O). Pneumonia is less likely given normal oxygen saturation and no focal findings."
Including one or two differentials, with a reason each is less likely, shows the reader you considered alternatives. Advanced practice programs usually expect a fuller differential discussion than RN programs.
Plan: Specific and Organized
The plan should let another clinician pick up the note and know exactly what happens next. If there are several problems, number the plan to match the assessment.
- Diagnostics: what is ordered and why.
- Treatment: medications with dose, route and frequency where your level allows, or nursing interventions.
- Education: what the patient is taught, including return precautions.
- Follow-up: when, with whom, and what would trigger an earlier review.
Check every plan item against the problem list. An item that maps to nothing means either the assessment is incomplete or the item does not belong.
Worked Example: Adult with a Cough
This example uses an instructor-style case scenario rather than a real patient. Notice how the assessment cites findings from both earlier sections, and how each plan item answers the assessment.
| Section | Example content |
|---|---|
| Subjective | "I've had this cough for about five days and it's getting worse, with thick yellow mucus. I feel tired and a bit feverish." Denies chest pain, shortness of breath at rest and haemoptysis. History of seasonal allergies. No current medications. No known drug allergies. |
| Objective | T 100.4°F, HR 92, RR 18, BP 124/78, SpO2 97% on room air. Rhonchi bilaterally in lower lobes, no wheeze. Productive cough observed. Throat mildly erythematous, no exudate. No lymphadenopathy. |
| Assessment | Acute bronchitis, likely viral, supported by a five-day productive cough (S), low-grade fever and bilateral rhonchi without focal consolidation (O). Early community-acquired pneumonia considered; less likely given normal SpO2 and no focal findings. |
| Plan | 1) Supportive care: fluids, rest, over-the-counter guaifenesin as needed. 2) Acetaminophen for fever or discomfort as needed. 3) Education: return if fever lasts beyond three days, breathlessness develops or symptoms worsen. 4) Follow-up in 7 to 10 days if not improved, sooner with red-flag symptoms. |
This is a teaching example. Treatment choices in your own note must follow your scenario, your scope of practice and your program's guidance.
SOAP Notes Inside Larger Assignments
SOAP notes are often one part of a bigger clinical write-up that also includes a pathophysiology discussion, differential analysis or patient education materials.
Keep the parts consistent. The reasoning in your assessment should match the disease process you explain elsewhere, and the plan should agree with any care plan on interventions and timing. For the wider structure, see our nursing case study format guide.
RN and Advanced Practice Notes Compared
The structure is the same at every level, but the depth changes. Check which expectations your course follows.
| Feature | RN-level note | Advanced practice note |
|---|---|---|
| Assessment | Nursing assessment and problem focus | Medical diagnosis with a fuller differential |
| Plan | Nursing interventions, education, escalation, coordination | Diagnostics, prescribing, referrals and follow-up |
| Length | Often under a page for one problem | Can run several pages for complex patients |
| Typical setting | Clinical logs, simulation, care coordination | Clinical rotations, focused and comprehensive visits |
A Simple Drafting Routine
Writing the four sections in order is not always the fastest route. Many students find it easier to sort the raw case details first, then write.
- Copy every detail from the scenario onto a scratch sheet.
- Label each detail S or O using the test above.
- List the problems those details point to, most urgent first.
- Write one assessment line per problem, citing at least one S and one O finding.
- Write the plan in the same numbered order, then check each item against its problem.
Finish by reading the note as if you were the next clinician on shift. Anything you would need to ask about is a gap to fill.
Common SOAP Note Mistakes
Most lost marks come from the same handful of errors. Run through this list before you submit.
- Interpretation or diagnosis language in the Objective section.
- Patient-reported pain scores placed under Objective; "states pain is 8/10" belongs in Subjective.
- An assessment that restates findings without synthesizing them.
- Vague plan items such as "monitor" or "educate" with no detail.
- Multi-problem notes that are not numbered consistently across Assessment and Plan.
- Missing pertinent negatives that would rule out serious differentials.
- Plan items that match nothing in the problem list.
- Mixing narrative first-person writing with clinical documentation style.
How NurseCapstone Helps with SOAP Notes
Send your case scenario or simulation data, your program level and the rubric. A writer matched to your level drafts a model note with a clear problem list and a plan that follows from it.
The note is written from scratch from the details you provide; we never invent patient encounters or clinical hours. Use it as a reference for your own documentation, with free revisions within the scope of your original request.
Want a Model SOAP Note for Your Case?
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Frequently Asked Questions
No. A SOAP note documents one encounter in four sections, while a care plan uses nursing diagnoses, goals, interventions and evaluation. Some assignments ask for both on the same patient.
Yes. For patients with several active problems, use a numbered problem list and address each one in the plan in the same order.
Yes. Most course SOAP notes are written from instructor-provided scenarios or simulation data rather than real patients.
A focused single-problem note may be under a page, while a complex graduate-level note can run several pages. Your rubric sets the expectation.
SOAP follows clinical reasoning from data to interpretation to plan. DAR (data, action, response) and PIE (problem, intervention, evaluation) are other nursing formats with the same principle of linking data to action.
Yes. Education with specific return precautions is a standard part of the plan and is often graded.
Widely recognized abbreviations are usually fine, but check whether your program or clinical site restricts any on safety grounds.
In the Subjective section, alongside the symptoms the patient reports. They show which red flags you screened for.