How to Write SOAP Notes Correctly: A Guide for NP Students
If you’re an NP student, learning to write SOAP notes is one of the most valuable skills you’ll carry throughout your career. More than just paperwork, SOAP notes show your ability to think critically, organize information, and communicate clearly with other providers.
Let’s break down each section of a SOAP note and review best practices for accuracy and clarity.
What is a SOAP Note?
SOAP is an acronym that stands for:
S – Subjective: What the patient tells you (their perspective, symptoms, history).
O – Objective: What you observe (vital signs, physical exam findings, lab/imaging results).
A – Assessment: Your clinical impression (diagnoses or differential diagnoses).
P – Plan: What you will do next (tests, treatments, referrals, education, follow-up).
This format ensures information is organized, concise, and easy for other providers to follow.
Subjective (S): The Patient’s Story
This section captures the patient’s words, symptoms, and concerns. Think of it as “what the patient says.”
Include:
Chief complaint (in the patient’s own words: “I’ve had a pounding headache for 3 days”)
History of present illness (location, duration, severity, triggers, alleviating factors)
Review of systems (relevant positives/negatives)
Past medical history, medications, allergies, family/social history (if applicable)
Tips:
Avoid medical jargon—write what the patient says.
Be specific: “sharp, 8/10 abdominal pain x 2 hours” is better than “stomach pain.”
Use quotation marks for direct quotes.
Objective (O): What You Observe
This section is fact-based: measurable, observable, or verifiable information.
Include:
Vital signs
Physical exam findings
Lab results, imaging, or diagnostic tests
General appearance
Tips:
Stick to observable data (e.g., “lung sounds diminished in right lower lobe”) rather than opinions (“patient seems sick”).
Document measurements precisely.
Assessment (A): Your Clinical Impression
This is where you analyze the information.
Include:
Primary diagnosis (supported by subjective + objective data)
Differential diagnoses (list alternatives if diagnosis isn’t certain)
Progress of existing conditions (improved, worsened, stable)
Tips:
Link your assessment back to the findings:
Example: “Hypertension—BP 152/92 in office today, patient reports headache and non-adherence to meds.”
Be concise but specific—avoid vague terms like “possible issue.”
Plan (P): Next Steps in Care
This section outlines what you will do for the patient. It should be detailed enough that another provider could follow it.
Include:
Labs or imaging ordered
Medications (dose, frequency, route)
Referrals (specialists, therapy, counseling)
Patient education (lifestyle, medication teaching)
Follow-up timeline
Tips:
Always include patient education and follow-up.
Write in a way that protects you legally: document teaching and the patient’s understanding.
Example: “Advised patient to take antibiotics with food, discussed GI side effects, encouraged use of probiotics. Patient verbalized understanding.”
Example SOAP Note (Download)
Want to see how it all comes together? I’ve created a sample SOAP note you can use as a guide for your own documentation practice.
📂 Click here to download the example SOAP note (Word document)
Use it as a reference, and try writing your own SOAP notes after each patient encounter — practice is the best way to build confidence and consistency.
Putting SOAP Notes Into Practice
SOAP notes are more than just documentation — they’re a reflection of your clinical reasoning. When written well, they highlight your ability to gather information, analyze it, and create an evidence-based plan of care.
For NP students, consistent practice is the key. Try writing a SOAP note after every patient encounter, even during clinical rotations. Over time, the process will feel more natural, build your confidence, and sharpen your critical thinking skills — all essential tools for your growth as a future provider.
Clinical Pearl: Always Include Cardio/Resp
When writing SOAP notes, remember that documentation is not just for your learning — it’s also a legal record and a communication tool for other providers. Even when the encounter is problem-focused (e.g., UTI, ear infection, rash), there are some systems you should always include in your documentation.
Rule of Thumb: Always include Cardiovascular and Respiratory in the Physical Exam (and often in ROS), regardless of the chief complaint.
✔ Patient Safety: Rules out systemic illness.
✔ Medico-Legal Protection: Shows you assessed for systemic involvement.
✔ Standards of Practice: Expected baseline in primary/urgent care.
✔ Clinical Habits: Builds consistency and prevents omissions.
Example – Problem-Focused Visit (UTI):
Cardiac: Regular rate and rhythm, no murmurs, rubs, or gallops.
Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
This takes less than 30 seconds in practice but strengthens both your clinical care and your documentation.
Michelle Brown, NP
Board-Certified Nurse Practitioner | Educator | Patient Advocate
Together, let’s grow in health and knowledge.
