A SOAP note is your clinical reasoning, written down.

01 / Background

What a SOAP note is, and why it works.

SOAP stands for Subjective, Objective, Assessment, Plan. It's a structured progress note introduced by Dr. Lawrence Weed as part of the problem-oriented medical record, and it's still widely used in nursing and medicine because the structure mirrors clinical reasoning. Many nursing programs and facilities use the extended SOAPIE format, which adds Intervention and Evaluation.

Every progress note is part of the legal medical record. Open RN's Nursing Fundamentals puts it plainly: documentation must be objective, factual, and professional, must include the date, time, and your signature, and follows the rule "if it wasn't documented, it wasn't done."

02 / Section by section

What belongs in each section.

S / Subjective

What the patient (or family) tells you: symptoms, concerns, and relevant history, quoted where it matters. "It hurts on my right side when I cough."

O / Objective

What you can observe or measure: vital signs, physical exam findings, intake and output, lab and diagnostic results. No interpretation yet.

A / Assessment

Your interpretation of S and O. In a nursing note, that means the patient's priority problems or nursing diagnoses, and whether they're improving, stable, or worsening.

P / Plan

What will be done, based on the assessment: nursing interventions, prescribed treatments, monitoring, teaching, and who you've notified.

03 / Worked example

A complete SOAP note for Mr. D.

Mr. D. is the fictional 72-year-old with community-acquired pneumonia from our head-to-toe assessment guide. Here's his day 2 morning assessment written as a nursing SOAP note. Times, values, and orders are illustrative; your facility's format and abbreviation list come first.

S

Patient states, "It hurts on my right side when I cough." Rates pain 4/10, sharp, worse with deep breaths. Reports dizziness when walking to the bathroom overnight. States he "didn't feel like eating" dinner.

O

0800: Temperature 38.4 °C, heart rate 104 and regular, respirations 24, blood pressure 128/76, SpO₂ 90% on 2 L/min nasal cannula. Alert and oriented ×4. Crackles in the right lower lobe; diminished breath sounds at the right base. Productive cough, moderate yellow sputum. Mucous membranes dry. Urine dark amber, 200 mL since 0000. Unsteady on standing; needed one-person assist. Dinner tray about 20% eaten. IV site clean and dry, no redness.

A

1. Ineffective airway clearance related to retained secretions, with impaired gas exchange: tachypnea, SpO₂ 90% on 2 L, right lower lobe crackles, productive cough. 2. Risk for deficient fluid volume: fever, poor oral intake, dry mucous membranes, concentrated urine. 3. Risk for falls: dizziness and unsteadiness on standing, age, acute illness.

P

Head of bed elevated; coached on coughing, deep breathing, and incentive spirometer use. Oxygen and antibiotic given as prescribed. Encouraged oral fluids; intake and output monitored. Fall precautions in place: bed low, call light in reach, assist with all ambulation. Respiratory status and SpO₂ to be reassessed per protocol. Provider notified of SpO₂ and urine output at 0820 using SBAR.

Notice what the example doesn't do. Nothing in O is interpreted ("lungs sound bad"), no medical diagnosis is invented in A, and the plan contains only actions the nurse performs, has prescribed, or has escalated. To see how the three problems in A become a full plan with outcomes and rationales, read the nursing care plan guide.

04 / Extended format

SOAPIE: adding Intervention and Evaluation.

In the SOAPIE format, I records what you actually did, and E records how the patient responded and whether the expected outcomes were met. For Mr. D., a later entry might read:

I

1000: Assisted to chair with one-person assist. Coached incentive spirometer, 10 breaths. Oral fluids 360 mL encouraged and taken.

E

1100: Respirations 20, SpO₂ 93% on 2 L/min. Coughing up sputum more easily. No dizziness during transfer. Fluid outcome partially met; continue to monitor.

The evaluation is where your reasoning closes the loop. "Partially met" with a reason tells the next nurse more than "patient tolerated well." Your facility may use a different format; see DAR and narrative notes for the same morning written other ways, and charting mistakes to avoid.

05 / Common errors

The mistakes instructors flag most.

• Opinions in O. "Patient seems anxious" belongs in A, supported by objective cues such as restlessness or a fast heart rate, or by the patient's own words in S.
• A that just repeats O. "SpO₂ 90%" is a finding, not an assessment. Say what it means and whether it's getting better or worse.
• Medical diagnoses you can't make. Nurses document nursing problems and responses. Record a provider's diagnosis as context ("admitted with pneumonia") rather than as your conclusion.
• Vague words. "Adequate," "good," "normal," and "tolerated well" don't tell the reader anything. Use measurements and the patient's own words.
• Unsafe abbreviations. The Joint Commission's "Do Not Use" list exists because abbreviations such as "U" for units and trailing zeros cause medication errors. Follow it and your facility's approved list.
• Plans with no follow-up. Every intervention needs a when or a who: reassess when, notify whom, monitor how often.

06 / Before you sign

SOAP note checklist.

Keep going with Mr. D.

Where the note comes from, and where it goes.