Master SOAP Documentation
Learn how to write professional, clear, and clinically accurate SOAP notes. These templates are used by nurses, students, and healthcare professionals worldwide.
S
Subjective
What the patient tells you
What to Include:
- Chief Complaint (CC) — Primary concern in 1 sentence
- History of Present Illness (HPI) — Onset, location, duration, characteristics, aggravating/relieving factors, timing, severity
- Associated Symptoms — Positive and negative findings ("denies...")
- Past Medical History — Relevant PMH/PSH, family history
- Medications & Allergies — Current meds, known allergies
- Social/Context — Relevant habits, exposures, recent events
- Patient's Own Words — Direct quotes when helpful
// Template
CC: [Patient's primary concern in 1 sentence] HPI: [Onset, location, duration, characteristics, aggravating/relieving factors, timing, severity] Associated Symptoms: - [Positive symptoms] - Denies: [Negative symptoms] PMH: [Relevant past medical/surgical history] Medications: [Current medications] Allergies: [Known allergies or NKDA] Social: [Relevant habits, exposures]
O
Objective
What you observe and measure
What to Include:
- Vital Signs — BP, HR, RR, Temp, SpO2, Weight
- General Appearance — Distress level, orientation
- Physical Exam Findings — Relevant systems examined
- Nursing Observations — Behavior, mobility, skin
- Labs/Imaging — Results if available
// Template
Vitals: BP: ___ HR: ___ RR: ___ Temp: ___ SpO2: ___ General: [Appearance, distress, orientation] HEENT: [Findings relevant to complaint] Chest/Lungs: [Respiratory effort, breath sounds] Cardiovascular: [Rate, rhythm, murmurs] Abdomen: [Bowel sounds, tenderness, guarding] Extremities: [ROM, edema, pulses] Neuro: [Alert/oriented, strength, sensation] Skin: [Color, lesions, wounds] Labs/Imaging: [Results if available]
A
Assessment
Your clinical reasoning
What to Include:
- Summary — Brief summary of key findings
- Differential Diagnoses — Prioritized list of possibilities
- Clinical Impression — Why you think this is the cause
- Red Flags — Concerning symptoms or absence of symptoms
- Patient Stability — Stable, improved, worsening, urgent
// Template
Assessment: [Brief summary of most important findings] Differential: 1. [Most likely condition] 2. [Second likely] 3. [Rule-out conditions] Clinical Impression: [Why you think this is the cause] Red Flags: [Any concerning symptoms or absence of symptoms] Patient Stability: [Stable / Improved / Worsening / Urgent]
P
Plan
What happens next
What to Include:
- Diagnostics — Tests ordered or recommended
- Treatment — Interventions performed, meds given
- Medications — New prescriptions, changes, refills
- Patient Education — Instructions, home care advice
- Follow-Up — When to return, what to monitor
- Safety Netting — Symptoms requiring urgent care
- Provider Notified — If nurse escalated care
// Template
Diagnostics: [Tests ordered or recommended] Treatment: [Interventions performed, meds given] Medications: [New prescriptions, changes, refills] Patient Education: [Instructions, home care advice] Follow-Up: [When to return, what to monitor] Return Precautions: [Symptoms requiring urgent care] Provider Notified: [Yes/No - if escalated]
🚨 Red Flag Guides
Chest Pain Red Flags
- • Radiation to jaw/arm
- • Shortness of breath
- • Diaphoresis
- • Syncope
- • "Worst pain of life"
Abdominal Pain Red Flags
- • Rebound tenderness
- • Vomiting blood
- • Rigid abdomen
- • Persistent fever
- • Signs of shock
Pediatric Red Flags
- • Lethargy / unresponsive
- • Signs of dehydration
- • Breathing difficulty
- • Rash + fever
- • Bulging fontanelle
Mental Health Red Flags
- • Suicidal ideation with plan
- • Self-harm
- • No sleep for days
- • Severe agitation
- • Command hallucinations
📋 What Providers Want
Providers reviewing your notes want documentation that is:
Concise
Objective
Organized
Relevant
Free of emotional language
Easy to review quickly
Safety-conscious
Legally defensible
Practice with Real Examples
See these templates in action with our library of clinical scenarios.
Browse Scenarios →These templates are for educational purposes only. Always follow your institution's documentation guidelines.