How to Write a SOAP Note (Nursing)
A SOAP note is a structured way to document a patient encounter in four parts — Subjective, Objective, Assessment, and Plan. Nurses and nursing students use this format to keep documentation organized, consistent, and easy for the whole care team to follow.
The 4 parts of a SOAP note
| Letter | What it means | What goes in it | Example |
|---|---|---|---|
| S | Subjective | What the patient tells you — symptoms, feelings, history, in their own words or paraphrased | "My chest feels tight and it's hard to catch my breath." |
| O | Objective | Measurable, observable data — vital signs, physical exam findings, labs, imaging | BP 150/94, HR 102, SpO2 94% on room air, lungs with bilateral crackles |
| A | Assessment | Your clinical judgment about what the subjective and objective data mean together | Acute shortness of breath, possibly cardiac in origin, given history and vitals |
| P | Plan | The next steps — treatments, monitoring, referrals, patient education | Notify provider, apply supplemental oxygen, reassess in 15 minutes, prepare for possible ECG |
A worked SOAP note example
Here's a short, realistic SOAP note for a patient being monitored for hypertension:
Once you're comfortable with the SOAP format, the next step is often turning that assessment into a full nursing care plan template — the same Subjective and Objective data feeds directly into your assessment section. If you haven't done one yet, our guide on how to write a nursing care plan walks through the whole process step by step.
SOAP note vs SBAR
A SOAP note is a charting format — it's how you document an assessment in the patient's record over time. SBAR (Situation, Background, Assessment, Recommendation) is a communication tool, typically used when you're calling a provider or handing off a patient and need to convey the most important information quickly and clearly.
Tips for writing better SOAP notes
- Keep Subjective data in the patient's own words when possible, using quotation marks.
- Only put measurable, observable facts in Objective — save your interpretation for Assessment.
- Make sure your Assessment actually connects back to the Subjective and Objective data you just wrote.
- Write the Plan as specific, actionable steps, not vague statements like "continue to monitor."
- Chart in a timely manner, while the encounter is still fresh, to avoid missing details.
- Avoid copying and pasting from previous notes without checking that the details still apply.
Building the whole care plan? Our free Care Plan Builder turns your assessment into a full care plan with diagnosis, goals, interventions and rationale.
Educational content for nursing students — not medical advice. Always follow your instructor's and institution's documentation standards.
Stop rewriting care plans by hand
CarePlanKit builds a complete, formatted care plan for any condition — assessment, diagnosis, SMART goals, interventions with rationale — free to start.
Build a care plan freeSOAP note: FAQ
How do you write a SOAP note for nursing?
Work through the four sections in order. Write down what the patient tells you in Subjective, then your objective findings — vitals, labs, physical exam — in Objective. In Assessment, state your clinical impression of what those findings mean, and in Plan, list the next steps for treatment, monitoring, and education.
What are the 4 components of a SOAP note?
Subjective, Objective, Assessment, and Plan. Subjective is the patient's own words and reported symptoms. Objective is measurable data like vital signs and exam findings. Assessment is your clinical judgment about the problem. Plan is what you and the care team will do about it.
What is an example of a SOAP note?
A short example: S — patient reports a headache rated 6/10 since this morning. O — BP 142/90, HR 88, alert and oriented, no visual changes noted. A — headache likely related to elevated blood pressure. P — recheck blood pressure in 30 minutes, notify provider if it stays elevated, encourage rest and hydration.
What is the difference between a SOAP note and SBAR?
A SOAP note is a documentation format used to record an ongoing assessment in the patient's chart. SBAR (Situation, Background, Assessment, Recommendation) is a communication tool used to hand off information verbally or in a quick written report, usually when contacting a provider or another nurse about a change in condition.
For nursing education only — NOT medical advice and not a clinical decision-making tool. Nothing here should be used to assess, diagnose, or treat any real patient. Care plans and answers are unverified study drafts to review with your instructor or a licensed clinician and adapt to the individual patient and your institution’s protocols before any use.