NURS-6512N-47: Advanced Health Assessment SOAP Notes for Advanced Practice Nurses: Best Practices → Templates, examples, common mistakes.

SOAP Notes for Advanced Practice Nurses: Best Practices

As an advanced practice nurse (APN), one of your key responsibilities is to accurately document patient encounters. The SOAP note format is a standardized method for documenting patient assessments, making it easier to organize and communicate information in a clear, concise, and systematic manner. SOAP stands for Subjective, Objective, Assessment, and Plan—four components that guide you in documenting patient history, clinical findings, diagnoses, and treatment plans.

In this post, we’ll explore the best practices for writing SOAP notes, provide templates and examples, and highlight some common mistakes to avoid.

SOAP Note Template

Here’s a breakdown of each component in the SOAP note format:

S – Subjective:
This section includes information gathered directly from the patient, or their family/caregiver, about their current condition, concerns, and history. It may also include pertinent information about their lifestyle, social history, or any symptoms they are experiencing.

Key elements to include:

• Chief Complaint (CC): A brief statement of the main reason for the visit, in the patient’s own words.

• History of Present Illness (HPI): A detailed account of the patient’s current symptoms, including the onset, duration, and quality.

• Review of Systems (ROS): A head-to-toe review of systems, documenting both positive and negative responses.

• Past Medical History (PMH), Social History (SH), Family History (FH), and Medications (if relevant).

Example:

• CC: “I’ve had this cough for the past three days.”

• HPI: The patient is a 35-year-old female who presents with a 3-day history of a dry, nonproductive cough. No associated fever or chills. Denies any shortness of breath or chest pain. The patient mentions she recently returned from a trip to the mountains.

• ROS: Negative for any headaches, dizziness, or chest discomfort. Denies hemoptysis.

O – Objective:
This section contains measurable or observable data obtained from the physical exam, lab results, diagnostic tests, or imaging.

Key elements to include:

• Vital signs (e.g., blood pressure, heart rate, respiratory rate, temperature, oxygen saturation)

• Physical exam findings (e.g., inspection, palpation, auscultation)

• Results of any tests or procedures (e.g., lab work, imaging)

Example:

• Vital Signs: BP 120/78, HR 82, RR 18, Temp 98.6°F, SpO2 98% on room air.

• Physical Exam: Lungs clear to auscultation bilaterally. No signs of respiratory distress. No wheezing or crackles noted. Neck supple with no lymphadenopathy.

• Laboratory Results: CBC shows mild elevation in WBC (11,000/uL), all other labs normal.

A – Assessment:
The assessment is where the APN synthesizes subjective and objective findings to determine the most likely diagnosis or differential diagnosis. This is your clinical judgment based on all gathered information.

Key elements to include:

• Diagnosis or differential diagnosis

• Rationale for your assessment, based on findings

• Any changes in the patient’s health status since the last visit (if applicable)

Example:

• Primary Diagnosis: Acute Viral Upper Respiratory Infection (URI)

• Differential Diagnoses: Allergic rhinitis, bacterial pneumonia

• Rationale: The patient’s 3-day history of a nonproductive cough, absence of fever, and clear lungs on exam support the diagnosis of a viral URI. The negative ROS and physical exam findings do not suggest a bacterial infection or pneumonia at this time.

P – Plan:
This section outlines your plan for treatment, management, and follow-up. It may include orders for medications, lifestyle recommendations, additional tests, referrals, or education for the patient.

Key elements to include:

• Therapeutic interventions (e.g., medications, referrals, physical therapy)

• Patient education

• Follow

SOAP Notes for Advanced Practice Nurses: Best Practices for Accurate Documentation

As an Advanced Practice Nurse (APN), effective documentation is a critical part of providing comprehensive patient care. One of the most common and standardized methods for documenting patient encounters is the SOAP note format. SOAP stands for Subjective, Objective, Assessment, and Plan—a simple structure that allows you to clearly communicate patient information, track progress, and develop appropriate treatment plans. Mastering the art of writing SOAP notes is essential for accurate record-keeping, effective clinical decision-making, and legal protection.

In this blog post, we’ll dive into best practices for writing SOAP notes, provide a SOAP note template, offer examples for advanced practice nurses, and highlight common mistakes to avoid in your documentation.

What is a SOAP Note and Why is it Important?

SOAP notes are a systematic way of documenting patient information in a structured format. They ensure that patient data is organized and easy to review by other healthcare providers, making it essential for collaborative care. SOAP notes for advanced practice nurses are especially important because they help you capture a detailed account of patient encounters, which supports clinical reasoning and helps improve patient outcomes.

The four sections of a SOAP note are:

• S – Subjective: Information provided by the patient or their caregiver.

• O – Objective: Measurable data observed by the healthcare provider.

• A – Assessment: Diagnosis or clinical impression based on subjective and objective findings.

• P – Plan: The treatment, management, and follow-up plan.

Best Practices for Writing SOAP Notes in Advanced Practice Nursing

To make your SOAP notes as effective and clear as possible, it’s essential to follow certain best practices:

1. Use Clear, Concise Language

In your SOAP notes, clarity is key. Avoid using vague or unnecessary terms. Keep your language simple and to the point, ensuring that anyone reading the note can easily understand the patient’s condition, plan, and reasoning.

2. Ensure Thoroughness in the Subjective Section

The Subjective section is your opportunity to understand the patient’s experience. Be specific about the chief complaint (CC), the history of present illness (HPI), and any relevant past medical, family, and social history. The more detailed and accurate this section, the better informed your clinical assessment will be.

3. Document Objective Findings with Precision

In the Objective section, record measurable data such as vital signs, physical exam findings, lab results, and imaging studies. Always ensure that you include precise numerical values when available, such as blood pressure, heart rate, and lab results. This allows for accurate tracking of changes in the patient’s condition.

4. Make Your Assessment Thoughtful and Evidence-Based

The Assessment is where you synthesize subjective and objective findings to form a clinical impression or diagnosis. Be sure to base your assessment on evidence—whether it’s clinical experience, patient history, or lab data—and document any differential diagnoses.

5. Create a Clear and Actionable Plan

In the Plan section, ensure that your treatment plan is clear, actionable, and follows the latest evidence-based guidelines. Include any medications, lifestyle changes, referrals, or follow-up appointments. Also, educate your patient about their condition and involve them in decision-making.

SOAP Note Template for Advanced Practice Nurses

Here’s a straightforward template to help you organize your SOAP notes:

S – Subjective:

• Chief Complaint (CC): (e.g., “I’ve been having a cough for 3 days.”)

• History of Present Illness (HPI): (e.g., “The patient reports a dry, nonproductive cough that started 3 days ago, with no fever or chills. Denies chest pain or shortness of breath. Recent travel to the mountains.”)

• Review of Systems (ROS): (e.g., “Denies headaches, dizziness, or chest pain.”)

• Past Medical History (PMH): (e.g., “Non-smoker, history of seasonal allergies.”)

• Social History (SH): (e.g., “Works as a teacher, lives with spouse, no alcohol use.”)

• Family History (FH): (e.g., “Father has hypertension, mother with diabetes.”)

• Medications: (e.g., “No current medications.”)

O – Objective:

• Vital Signs: (e.g., BP 120/78, HR 80, Temp 98.7°F, RR 16, SpO2 98%)

• Physical Exam: (e.g., “Lungs clear to auscultation bilaterally. No wheezing, crackles, or signs of respiratory distress. Neck supple, no lymphadenopathy.”)

• Lab Results: (e.g., “CBC shows WBC count of 11,000/uL. All other labs normal.”)

A – Assessment:

• Primary Diagnosis: Acute viral upper respiratory infection (URI)

• Differential Diagnosis: Allergic rhinitis, bacterial pneumonia

• Clinical Rationale: Based on the patient’s history, presentation, and exam findings, the most likely diagnosis is viral URI. The absence of fever and abnormal lung sounds suggests no evidence of bacterial infection at this time.

P – Plan:

• Medications: Symptomatic treatment with over-the-counter antihistamines and fluids.

• Lifestyle: Increase hydration, rest, avoid irritants.

• Follow-Up: Follow up in 1 week if symptoms persist or worsen.

• Patient Education: Educated on viral vs. bacterial infections and the role of antibiotics.

Examples of SOAP Notes for Advanced Practice Nurses

Example 1: Respiratory Infection

S: The patient presents with a 4-day history of cough and sore throat. Denies fever or chills. The cough is dry and persistent. No history of asthma or smoking.
O: Temp 98.6°F, BP 130/80, HR 88, RR 18, SpO2 97% on room air. Lungs clear to auscultation. No cervical lymphadenopathy.
A: Acute viral upper respiratory infection.
P: Recommend symptomatic treatment with hydration, OTC cough syrup, and rest. Follow-up if no improvement in 5-7 days.

Example 2: Diabetes Management

S: A 55-year-old male with a 10-year history of type 2 diabetes reports feeling more fatigued lately. He also mentions increased thirst and frequent urination.
O: Weight 210 lbs, BP 145/90, HR 82, blood glucose 190 mg/dL. Pedal pulses are weak.
A: Poorly controlled diabetes with possible signs of diabetic complications.
P: Increase insulin dosage, refer to a diabetic educator, encourage a low-carb diet, and schedule a follow-up appointment in 2 weeks for reassessment of blood glucose control.

Common Mistakes to Avoid in SOAP Notes

While writing SOAP notes, there are common mistakes to be aware of that can lead to incomplete or unclear documentation:

1. Being Vague in the Subjective Section

Avoid using general statements like “patient reports feeling unwell.” Be specific about symptoms and their duration, location, and characteristics.

2. Inaccurate or Incomplete Objective Findings

Ensure all measurable data is included and clearly documented. Missing vital signs, lab results, or incomplete physical exam findings can lead to an inaccurate clinical picture.

3. Lack of Clarity in the Assessment

Avoid leaving your assessment vague. Provide a clear rationale for your diagnosis and differential diagnoses. Always justify your clinical reasoning based on the findings.

4. Failure to Document the Plan of Care

The Plan section should be detailed and actionable. If you fail to outline a clear course of action, it could lead to confusion or missed follow-up.