SOAP Notes for Nurses: Format, Tips and a Fictional Example
SOAP is a problem-oriented note structure: Subjective, Objective, Assessment, Plan. Many nursing programs and some facilities extend it to SOAPIE by adding Intervention and Evaluation.
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The four sections
- Subjective: what the patient or family tells you, ideally in their own words
- Objective: what you can measure or observe, such as vital signs, assessment findings and results
- Assessment: your nursing interpretation of the subjective and objective data
- Plan: what will be done, by whom and when
In SOAPIE, Intervention records what you actually did and Evaluation records the response.
Keep each section honest
A frequent mistake is mixing sections: putting your interpretation in Objective or a new finding in Plan. Objective should contain only data someone else could verify. Assessment must follow from the data above it, not introduce new facts.
A fictional example
S: 'My incision is throbbing, about a 6.' O: Day 1 after fictional abdominal surgery. Incision edges approximated, no drainage, mild guarding. T 37.2, HR 88, BP 128/76. A: Pain not controlled at current level; incision appears clean. P: Give PRN analgesic as ordered, reposition, reassess within the policy timeframe. I: Analgesic given 10:05, repositioned. E: 10:45 rates pain 3/10, resting.
When SOAP fits best
SOAP suits problem-focused entries: a new symptom, a change in condition or a focused reassessment. For a long sequence of events, a narrative note in time order is often clearer.