What is a nursing SOAP notes template?
A nurse practitioner commonly uses SOAP notes to record all kinds of clinical documentation during a patient encounter or visit. The SOAP acronym stands for the four sections of the note: subjective, objective, assessment, and plan. Let's take a look at what each section should contain:
- Subjective: Here, you'll document key points about your patient's subjective experience. This includes what the patient reports, such as their chief complaint (e.g., chest pain or abdominal pain), past medical history, surgical history, social history, allergies, current medications, and any other relevant details they share about their condition or experience.
- Objective: The objective section of the SOAP note is for the information you can measure and observe. Objective data on your patient might include their vital signs, appearance, histology, radiology, or physical exam results.
- Assessment: In this section, you'll summarize your conclusions about the patient's current condition based on the subjective and objective information gathered earlier. This could take the form of a primary diagnosis with differential diagnoses or a holistic overview of the patient's issues. Strong clinical reasoning is essential to connect the findings and support your conclusions.
- Plan: Outline the next steps based on the identified issues for your patient. This section should detail immediate actions taken, materials provided, referrals made, prescribed medications, and any patient education offered.
Fortunately, our template already has the four sections of SOAP Notes laid out for you, with space for you to fill them in as you interact with your patient and to write down your patient's details to help them with their present illness.










