Examples of SOAP Notes for Advanced Practice Nurses Example 1: Acute Respiratory Illness

Examples of SOAP Notes for Advanced Practice Nurses

Example 1: Acute Respiratory Illness

CC: “I’ve been coughing for the last 5 days and I feel tired.”
HPI: A 42-year-old female presents with a 5-day history of a dry, nonproductive cough. Reports mild fatigue but denies fever, chills, or shortness of breath. No known exposure to sick contacts.
ROS: Denies headaches, chest pain, or gastrointestinal complaints.
PMH: Non-smoker, no significant medical history.
Medications: Takes no daily medications.

Vital Signs: BP 118/76, HR 76, Temp 98.6°F, RR 18, SpO2 97% on room air.
Physical Exam: Lungs clear to auscultation, no wheezes or crackles. Throat non-erythematous. No lymphadenopathy.
Lab Results: CBC within normal limits, no signs of infection.

Diagnosis: Likely viral upper respiratory infection.
Differential: Allergic rhinitis, bronchitis.
Rationale: Negative ROS for typical bacterial infection symptoms, normal physical exam.

Medications: Recommend OTC antihistamine and saline nasal spray.
Follow-up: Return in 7 days if no improvement or if symptoms worsen.
Patient Education: Educated on viral illness course and the importance of rest and hydration.

Example 2: Diabetes Management

CC: “I’ve been feeling more thirsty lately and have been urinating a lot.”
HPI: A 58-year-old male with a 10-year history of Type 2 diabetes reports increased thirst, frequent urination, and feeling more fatigued over the past few weeks.
ROS: Denies any chest pain, dizziness, or blurred vision.
PMH: Type 2 diabetes, hypertension.
Medications: Metformin 500 mg twice daily.

Vital Signs: BP 145/92, HR 78, Temp 98.6°F, RR 16, SpO2 98%.
Physical Exam: No signs of diabetic neuropathy. Feet intact with no ulcers.
Lab Results: Fasting blood glucose 210 mg/dL, HbA1c 9.2%.

Diagnosis: Poorly controlled diabetes, likely due to non-adherence to prescribed therapy.
Differential: Diabetic nephropathy, dehydration.
Rationale: Elevated blood glucose and HbA1c indicate poor diabetes control, which could explain increased thirst and urination.

Medications: Increase metformin dose to 1000 mg twice daily.
Follow-up: Schedule follow-up in 2 weeks to reassess blood glucose control.
Patient Education: Reviewed importance of consistent medication adherence, diet, and exercise.

Common Mistakes to Avoid When Writing SOAP Notes

Even experienced APNs can make mistakes in SOAP note documentation. Here are some common errors to avoid:

1. Vague or Incomplete Subjective Information

Always include specific details about the patient’s symptoms, history, and other relevant information. Avoid statements like “patient feels bad” and ensure you capture clear descriptions.

2. Omitting or Inaccurately Recording Objective Data

Make sure all important physical exam findings and diagnostic results are recorded in detail. Missing out on crucial data can lead to misdiagnosis or incomplete patient care.

3. Not Providing a Clear Rationale in the Assessment

Your diagnosis should always be supported by the data you’ve gathered. Avoid jumping to conclusions without justifying your clinical reasoning.

4. Inadequate Planning or Follow-up

Your Plan section should be clear, comprehensive, and actionable. Always provide timelines for follow-up, recommendations for referrals, and patient education.

Conclusion: Mastering SOAP Notes for Advanced Practice Nurses

Mastering SOAP notes for advanced practice nurses is essential for effective patient care, communication, and legal protection. By following the best practices outlined above and using clear, evidence-based documentation, you can ensure that your SOAP notes are both useful and accurate. This skill is vital not only for tracking patient progress but also for providing high-quality, patient-centered care in any healthcare setting.

With consistent practice, writing SOAP notes will become second nature and a key part of your professional routine.