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

As a nursing student, mastering the art of writing clear and concise SOAP notes is essential. SOAP notes are a standardized method of documentation used by healthcare professionals to record patient encounters. SOAP stands for Subjective, Objective, Assessment, and Plan—each section capturing vital information that helps guide patient care.

This guide breaks down each component and provides practical tips to help you write effective SOAP notes during clinicals and coursework.

What is a SOAP Note?

A SOAP note organizes clinical information into four sections:

S (Subjective): The patient’s description of their symptoms and feelings.
O (Objective): Measurable and observable data collected during the physical exam or tests.
A (Assessment): Your professional interpretation or diagnosis based on subjective and objective data.
P (Plan): The proposed treatment or next steps to address the patient’s condition.

Step 1: Subjective (S)

In this section, document what the patient tells you about their condition. This includes:

Chief complaint (CC): The main reason for the visit.
History of present illness (HPI): Details like onset, duration, severity, and associated symptoms.
Relevant past medical, family, and social history.
Patient’s feelings or concerns.

Example:
“Patient reports a headache for three days, described as throbbing and moderate intensity. Denies nausea or vision changes.”

Step 2: Objective (O)

Record your physical examination findings and any diagnostic results:

Vital signs: blood pressure, heart rate, temperature, respiratory rate.
Physical exam observations: skin color, pupil reaction, lung sounds.
Lab or imaging results.

Example:
“BP: 130/85 mmHg, HR: 78 bpm, Temp: 98.6°F. Pupils equal and reactive. Lungs clear bilaterally.”

Step 3: Assessment (A)

Provide your clinical judgment here. This could be a diagnosis, differential diagnosis, or problem list.

Example:
“Tension headache likely due to stress. No signs of infection or neurological deficit.”

Step 4: Plan (P)

Outline your plan for treatment and management, including:

Medications prescribed or recommended.
Patient education or lifestyle advice.
Follow-up appointments or referrals.
Any additional tests ordered.

Example:
“Recommend over-the-counter analgesics PRN. Advise stress reduction techniques. Follow up in one week or sooner if symptoms worsen.”

Tips for Writing Effective SOAP Notes

Be concise but thorough.
Use medical terminology accurately.
Avoid personal opinions—stick to factual information.
Write in past tense for subjective and objective data.
Keep your notes organized and legible.

Why Are SOAP Notes Important?

SOAP notes ensure clear communication among healthcare team members, provide a legal record, and support quality patient care. Developing this skill early will help you succeed academically and professionally.