SOAP Notes for Advanced Practice Nurses: Best Practices for NURS-6512N-47

SOAP Notes for Advanced Practice Nurses: Best Practices for NURS-6512N-47

→ Templates, examples, and common pitfalls to avoid

In NURS-6512N-47: Advanced Health Assessment, developing accurate, detailed, and clinically relevant SOAP notes is a core skill. These structured clinical notes help nurse practitioners and students communicate effectively, support diagnostic reasoning, and document care for legal and professional standards.

📄 What Is a SOAP Note?

SOAP stands for:

• Subjective: What the patient reports

• Objective: What you observe, measure, or assess

• Assessment: Your clinical interpretation

• Plan: Next steps in care

SOAP notes are used for everything from routine checkups to complex differential diagnoses and serve as vital documentation in electronic health records (EHRs).

✅ SOAP Note Template for APNs

Here’s a practical SOAP note outline tailored for NURS-6512N-47:

S – Subjective

• Chief Complaint (CC): “I’ve had a sore throat for 3 days.”

• History of Present Illness (HPI):
  Onset, Location, Duration, Characteristics, Aggravating/Relieving factors, Treatment, Severity (OLDCARTS)

• Past Medical History (PMH): Chronic conditions, surgeries

• Medications: Include OTC and herbal

• Allergies: Medication, food, environmental

• Social History: Tobacco, alcohol, drug use, occupation

• Family History: Relevant genetic risks

• Review of Systems (ROS): Systematic yes/no checklist by body system

O – Objective

• Vital Signs: BP, HR, Temp, RR, O2 sat

• Physical Exam Findings: Inspection, palpation, auscultation, percussion (by system)

• Labs/Imaging: Any recent or pending diagnostics

• General Appearance: “Alert and oriented, no distress.”

A – Assessment

• Primary Diagnosis: Include ICD-10 code

• Differential Diagnoses: 2–3 possible conditions with rationale

• Link subjective and objective findings to justify your clinical judgment

P – Plan

• Diagnostics: Labs, imaging

• Medications: Name, dose, route, frequency

• Education: What the patient should know/do

• Follow-up: When to return or call

• Referrals: If applicable

• Preventive care: Vaccines, screenings, lifestyle coaching

📘 SOAP Note Example: Acute Pharyngitis

S:
CC: “My throat hurts when I swallow.”
HPI: 32-year-old female with 3-day sore throat, worse in the morning, denies cough or congestion.
PMH: None. No current meds. Allergic to penicillin.

O:
Temp: 101.2°F; HR: 92; BP: 118/72
Tonsils enlarged with exudates, cervical lymphadenopathy, no nasal congestion. Rapid strep test positive.

A:
Acute streptococcal pharyngitis (ICD-10: J02.0)
DDx: Viral pharyngitis, mononucleosis

P:
Prescribed azithromycin 500 mg day 1, then 250 mg x4 days
Patient education on hydration and rest
Follow-up in 3 days if symptoms persist or worsen

❌ Common SOAP Note Mistakes to Avoid