A SOAP note is one of the first pieces of clinical documentation nursing programs grade closely, because it teaches you to separate what the patient tells you from what you observe, and to justify your plan with your own findings. This guide walks through each section, a worked example, and the mistakes that cost the most marks.
SOAP stands for Subjective, Objective, Assessment and Plan. It is a structured way of documenting a single patient encounter, whether that is a clinic visit, a shift assessment, or a focused follow-up on one problem. Nursing programs assign SOAP notes because the format forces a specific kind of clinical thinking: state what the patient reports, record what you actually measured or observed, form a judgment that is grounded in that data, and then act on the judgment. A note that skips a step, or blends steps together, usually signals to a grader that the underlying reasoning has a gap too.
Unlike a narrative note, which can wander through an encounter in whatever order it happened, a SOAP note imposes order on the information. That is precisely why programs use it as a teaching and grading tool. It is easier to see whether a student's assessment is actually supported by data when the data has to sit in its own labeled section, separate from the interpretation.
The Subjective section holds information that comes from the patient (or, when relevant, a family member or caregiver) in their own words or closely paraphrased. This includes the chief complaint, the history of the present problem, relevant past medical history the patient reports, current medications and allergies as the patient states them, and pertinent review-of-systems responses. Anything you did not personally observe or measure, but were told, belongs here.
A well-written Subjective section usually opens with the chief complaint in the patient's own words, often in quotation marks, followed by an organized history using a recognized framework. Many programs teach OLDCARTS or PQRST for symptom history:
| OLDCARTS Element | What It Captures |
|---|---|
| Onset | When the symptom started and how (sudden or gradual) |
| Location | Where the symptom is felt |
| Duration | How long it has lasted, or how long each episode lasts |
| Character | What it feels like (sharp, dull, burning, cramping) |
| Aggravating/Alleviating factors | What makes it worse or better |
| Radiation | Whether it spreads or moves elsewhere |
| Timing | Constant, intermittent, or tied to activity/time of day |
| Severity | Usually a 0 to 10 scale, in the patient's own rating |
Keep interpretation out of this section. If the patient says "the pain is a 7 and gets worse when I walk," write exactly that. Do not write "the patient appears to have worsening pain," because "appears" is your judgment, and judgment belongs in Assessment, not Subjective.
The Objective section is strictly measurable, observable, or documented fact: vital signs, physical exam findings, laboratory results, diagnostic imaging findings, and anything charted by another clinician that you are citing directly (such as a prior provider's note). Nothing the patient told you belongs here unless it is something you independently verified, such as confirming a medication list against the chart.
Organize the Objective section logically, usually vital signs first, then a general appearance statement, then a system-by-system exam (or a focused exam if the assignment specifies one problem), then any lab or diagnostic data available at the time of the encounter. Use precise, professional terminology rather than vague description. "Lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi" is objective and specific. "Breathing sounds okay" is neither.
The fastest way to check your own note: read only the Objective section out loud. If a sentence contains a word like "seems," "reports," "states," or "appears to be," it has drifted into Subjective or Assessment territory and needs to move.
The Assessment section is where you interpret the Subjective and Objective data and state your clinical impression. At the student level, this usually means identifying the primary problem or nursing diagnosis, and briefly noting differential considerations if the assignment calls for them, always tying the impression back to specific findings already documented above. This is the section markers scrutinize most closely, because it is where your clinical reasoning becomes visible.
A strong Assessment statement names the problem and explains, in one or two sentences, why the data supports it. For a nursing-focused SOAP note, this is often written as (or alongside) a formal nursing diagnosis, for example "Acute pain related to surgical incision as evidenced by patient-reported pain rating of 7/10 and guarding behavior noted on exam," rather than a bare diagnosis with no supporting data attached to it.
Avoid two opposite failure modes here. The first is an Assessment that is not actually justified by the Objective section, for example concluding "likely infection" when no fever, no abnormal white count, and no wound findings were documented above. The second is an Assessment that just repeats the data instead of interpreting it, for example writing "temperature 101.2, heart rate 110" again instead of stating what that combination means clinically.
The Plan section states the concrete actions that follow from the Assessment: nursing interventions, patient education, medications to administer or recommend (within your scope and the assignment's scope), monitoring parameters, follow-up timing, and any referrals. Every action in the Plan should trace back to something named in the Assessment. If your Assessment identifies pain as the primary problem, the Plan should address pain, not drift into an unrelated topic with no supporting rationale.
Specificity is what separates a strong Plan from a weak one. "Continue to monitor" says nothing a grader can evaluate. "Reassess pain using 0 to 10 scale 30 minutes after PRN analgesic administration and document response" tells the reader exactly what will happen, when, and how it will be documented. Where the assignment expects patient education, name the actual content taught (for example, incision care and signs of infection to report) rather than writing "patient educated" with no detail.
Students sometimes conflate a SOAP note with a nursing care plan, but the two serve different purposes. A SOAP note documents a single encounter or a single point in time: what was reported, found, concluded, and decided at that moment. A nursing care plan is a broader, ongoing document built around one or more nursing diagnoses, each with its own goals, expected outcomes, planned interventions with rationale, and an evaluation of whether the goal was met over a period of care, not just one visit.
In practice, a SOAP note might document today's assessment and today's plan for a single problem, while a care plan tracks that problem's full trajectory, its priority relative to other diagnoses, and how outcomes are being measured over days or weeks. If your assignment asks for goals, expected outcomes stated in measurable terms, and an evaluation section, you are very likely being asked for a care plan rather than a SOAP note. See our nursing care plan writing guide for that format specifically, and check your rubric before choosing a structure.
Share the case details, rubric and format your program requires, and get a clean, correctly organized note.
The scenario and patient below are entirely invented for teaching purposes. No real patient data is used or implied anywhere in this example, and it should be treated only as an illustration of format and reasoning, not a template to copy into an actual assignment.
| Section | Content |
|---|---|
| Subjective | Fictional patient, 34 years old, reports "sharp pain on the right side of my lower belly that started yesterday evening and has gotten worse." Rates pain 6/10, worse with movement, no relief with position change. Denies fever at home. No known drug allergies. No past abdominal surgery reported. |
| Objective | Temperature 100.9°F, heart rate 98, blood pressure 122/78, respiratory rate 18. Abdomen tender to palpation in right lower quadrant with voluntary guarding, no rebound tenderness noted on this exam. Bowel sounds present in all four quadrants. |
| Assessment | Acute abdominal pain, right lower quadrant, of unclear origin, with low-grade fever and localized tenderness raising concern for an underlying process requiring further evaluation. Findings are not conclusive for a specific diagnosis on nursing assessment alone. |
| Plan | Notify supervising provider of findings for further evaluation and possible imaging or lab work. Continue to monitor vital signs every 30 minutes. Keep patient NPO pending provider assessment. Reassess pain score after any intervention and document response. Educate patient on the reason for NPO status and expected next steps. |
Notice that the Assessment does not leap to a specific diagnosis the nursing scope does not support, and the Plan flows directly from what was found, rather than introducing unrelated actions.
A pertinent negative is a finding that is absent but still worth recording, because its absence helps narrow down what is and is not happening with the patient. In the abdominal pain example used later in this guide, "no rebound tenderness" is a pertinent negative: it does not tell you what is wrong, but it helps rule out certain possibilities and is exactly the kind of detail a provider would want to know when deciding what to do next. Students sometimes leave pertinent negatives out of a SOAP note because nothing was technically "found," but a grader reading only positive findings often cannot tell whether a relevant sign was checked and absent, or simply never checked at all. When in doubt, document that you checked, and what you found or did not find.
The same logic applies to the Subjective section. If a symptom commonly associated with the chief complaint is absent, note it. A patient presenting with chest discomfort who denies shortness of breath, diaphoresis, or radiation to the arm or jaw has given you information that shapes the clinical picture just as much as a symptom they do report.
Most nursing programs expect a SOAP note to follow a few style conventions consistently, even though the exact rubric wording varies. Use standard, approved medical abbreviations only, and spell out anything your program flags as a "do not use" abbreviation (some institutions maintain their own banned abbreviation list to prevent misreading, a practice carried over from real clinical documentation standards). Write in the past tense for what was found during this encounter, and keep tense consistent across all four sections. Avoid absolute language such as "normal" without specifying what was actually assessed, since "abdomen normal" tells a reader far less than "abdomen soft, non-tender, non-distended, bowel sounds present in all four quadrants."
Keep the four section headings visible and in order, even in a flowing academic paper format, so a grader can immediately locate where a particular piece of information was placed. If your program supplies a specific SOAP note template, use it exactly, since minor formatting deviations are an easy and entirely avoidable way to lose points that have nothing to do with your clinical reasoning.
SOAP and SBAR solve related but different problems. A SOAP note documents a full encounter with structured clinical reasoning, usually written after the fact. SBAR (Situation, Background, Assessment, Recommendation) is built for a focused, time-pressured handoff or escalation conversation, where the goal is getting critical information across quickly and clearly rather than documenting an entire assessment. Some programs ask students to practice moving from a SOAP note's Assessment and Plan into a short SBAR script, since the Assessment sections of both formats overlap in purpose even though the surrounding structure differs. If your course covers both, our SBAR communication guide covers that format in the same depth.
Follow your program's rubric and the sample notes it provides. Many clinical settings favor concise, fragment-style documentation for speed, while academic SOAP note assignments often expect fuller sentences that demonstrate reasoning clearly. When in doubt, ask your instructor which style is being graded.
Only if your assignment specifically asks for differentials. Many nursing SOAP note assignments expect a primary nursing diagnosis or clinical impression rather than a full medical differential list, since that list is typically the provider's responsibility. Check your rubric before adding content that was not requested.
If your assignment asks you to support your reasoning with evidence, such as citing a clinical guideline for your plan, use APA 7 formatting unless told otherwise. See our APA 7 guide for reference and in-text citation formatting.
De-identify it completely. Change any detail that could identify the patient, facility, or date, and follow your program's specific policy on using clinical experiences in coursework.
They use the same underlying structure, but an academic SOAP note assignment is usually longer and more explanatory than a real clinical chart entry, because it is also demonstrating your reasoning process to a grader, not just documenting care.
A strong SOAP note keeps each section doing its own job: Subjective reports what the patient said, Objective records what you measured, Assessment interprets that data into a clinical impression, and Plan acts on the impression with specific, traceable steps. Once that separation becomes automatic, the format stops feeling like a rigid template and starts working the way it was designed to, as a tool for clear clinical thinking.
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