🩺 How to Write a SOAP Note: A Step-by-Step Guide for Nursing and Medical Students

If you’re training in nursing, medicine, or any clinical setting, one skill you must master is writing a SOAP note. It’s one of the most widely used methods for documenting patient care, and knowing how to write a SOAP note ensures clear, accurate, and effective communication between healthcare providers.

This guide will walk you through each section of a SOAP note—with explanations, real examples, and tips to help you write like a pro. 🩹

📌 What is a SOAP Note?

A SOAP note is a structured way for healthcare professionals to document patient encounters. The acronym stands for:

S – Subjective
O – Objective
A – Assessment
P – Plan

SOAP notes are used in hospitals, clinics, mental health settings, and nursing homes. They provide a consistent format for tracking progress, diagnosing, and planning care.

🧱 Structure of a SOAP Note

Here’s a breakdown of what goes into each part:

Section	Meaning	Includes
S – Subjective	What the patient tells you	Symptoms, complaints, pain scale, history in patient’s words
O – Objective	What you observe or measure	Vital signs, physical exam findings, test results
A – Assessment	What you think is happening	Diagnosis or differential diagnosis
P – Plan	What you’ll do next	Treatment plan, referrals, medications, follow-up

📝 How to Write a SOAP Note Step-by-Step

Let’s break down each section with detail and examples.

1. S – Subjective 🗣️

This is the patient’s story. Include:

Chief complaint (CC)
History of present illness (HPI)
Symptoms (location, quality, duration, severity, timing)
Medical history, medications, allergies
Lifestyle factors (diet, sleep, stress, etc.)

👉 Example:
“Patient reports a sore throat for the past three days. Describes pain as sharp and rates it 6/10. Denies cough or fever. States difficulty swallowing and mild headache.”

Tips:

Use quotation marks for direct statements: “It feels like I’m swallowing glass.”
Include relevant negative responses (e.g., “denies chest pain”).

2. O – Objective 👀

Here, you record factual data from your observations or tests.

Include:

Vital signs (BP, HR, Temp, RR)
Physical exam results (inspection, palpation, auscultation, percussion)
Lab or diagnostic findings (CBC, imaging, urinalysis)

👉 Example:

Temperature: 100.4°F
BP: 118/76, HR: 90 bpm
Throat erythematous with enlarged tonsils
No exudate or lymphadenopathy
Rapid strep test: Negative

Tips:

Stick to measurable facts
List abnormal findings clearly

3. A – Assessment 🧠

This is your clinical judgment.

Include:

Primary diagnosis
Differential diagnoses (if applicable)
Progress since last visit (if follow-up)

👉 Example:

Acute pharyngitis – likely viral origin
R/O streptococcal pharyngitis (pending throat culture)

Tips:

Match your assessment with what’s supported in the Subjective and Objective sections
Use ICD-10 codes if required in your setting

4. P – Plan 📝

Now, outline the next steps in the patient’s care.

Include:

Medications prescribed (dose, route, frequency)
Tests ordered
Patient education (diet, activity, medication use)
Referrals or follow-up instructions

👉 Example:

Prescribed ibuprofen 400mg PO q6h prn for pain
Advised saltwater gargle and hydration
Follow-up in 3–5 days if symptoms persist or worsen
Pending throat culture results

Tips:

Be clear and specific
If patient refuses treatment, document it
Include patient understanding or compliance when possible

✨ SOAP Note Example

S: Patient reports mild chest discomfort after meals for the past two weeks. Describes it as a burning sensation, rated 5/10. Denies shortness of breath or nausea. History of GERD.

O: BP: 130/82, HR: 72 bpm, Temp: 98.6°F. Abdomen soft, non-tender. Mild epigastric tenderness noted. No masses. EKG normal.

A: GERD exacerbation likely due to dietary triggers. Rule out peptic ulcer.

P: Advised patient to avoid spicy foods and caffeine. Prescribed omeprazole 20mg once daily before breakfast for 14 days. Schedule follow-up in 2 weeks.

✅ Do’s and Don’ts of SOAP Notes

✅ DO:

Stay clear, concise, and organized
Use medical terminology correctly
Focus on facts and avoid assumptions
Document refusals and patient feedback
Double-check for accuracy before submission

❌ DON’T:

Use slang or abbreviations that aren’t standard
Forget to date/time the note
Include emotional or judgmental language
Skip over key symptoms or findings
Write in long paragraphs—use bullet points when needed

📚 SOAP Note Writing Checklist

Use this quick checklist before finalizing your note:

Did I include all relevant subjective details?
Are the objective findings documented clearly?
Is the assessment evidence-based and aligned with data?
Is the plan actionable and complete?
Did I write in a professional and neutral tone?

📣 Final Thoughts: Write SOAP Notes with Confidence

Whether you’re a nursing student, medical intern, or physician assistant in training, knowing how to write a SOAP note is an essential clinical skill.

A well-written SOAP note isn’t just paperwork—it’s a tool for continuity of care, collaboration, and accountability in the medical field.

So take your time, follow the structure, and always write with accuracy and purpose. Your patients—and your team—are counting on it. 🩺🖊️

🚀 Need Help with SOAP Notes or Clinical Documentation?

At Study Doll, we support nursing and medical students with documentation coaching, SOAP note templates, and academic writing help tailored to your field.

👉 Click here to order expert help now — and master the art of writing clear, professional SOAP notes with ease!