Nursing
A SOAP note is a structured clinical documentation format that organizes patient encounter data into four sections: Subjective, Objective, Assessment, and Plan. Developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record (POMR), the SOAP format remains the standard for clinical documentation in nursing education and practice. SOAP notes train nursing scholars to translate a clinical encounter into a concise, organized record that communicates the patient's status, the clinical reasoning behind the assessment, and the plan of care to every member of the interdisciplinary team.
ScribeLabWriter provides SOAP note writing support led by a registered nurse with a Master's degree in Clinical Research. We produce SOAP notes formatted to your program's exact rubric, clinical setting, and documentation standards across BSN, MSN, and DNP levels.
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The subjective section documents what the patient reports in their own words. This includes the chief complaint, history of present illness (HPI), relevant medical history, current medications, allergies, family history, social history, and review of systems. Use direct quotation marks for patient statements where appropriate (for example, "I feel like I can't catch my breath when I walk to the bathroom").
The subjective section captures the patient's perspective. It does not include clinical measurements, test results, or the nurse's interpretation.
The objective section documents measurable, observable clinical findings. This includes vital signs, physical examination findings, laboratory results, diagnostic imaging results, and any other quantifiable data collected during the encounter. The objective section reports facts, not interpretations.
In nursing SOAP notes, the objective section also includes relevant nursing assessments: wound measurements, pain scale scores (documented as the tool used and the score, for example "NRS 6/10"), intake and output records, and functional status observations.
The assessment section is the clinical interpretation. It connects the subjective and objective data to form a clinical judgment. In nursing SOAP notes, the assessment identifies the primary nursing concern or diagnosis, explains the clinical reasoning linking the S and O data, evaluates the patient's response to current treatment or interventions, and identifies any changes in patient status.
The assessment is the section that demonstrates clinical reasoning. It is the most common section where marks are lost because it requires the writer to analyze and interpret, not just report.
The plan section documents the next steps in patient care. This includes orders, interventions, referrals, follow-up appointments, patient education provided, and any changes to the current plan of care. The plan should address every concern identified in the assessment.
A complete plan includes: diagnostic plans (tests or monitoring ordered), therapeutic plans (medications, procedures, or nursing interventions), patient education plans (what was taught and how comprehension was verified), and follow-up plans (when and how the patient will be reassessed).
The content and focus of a SOAP note shifts depending on the clinical setting:
| Setting | Subjective Emphasis | Objective Emphasis | Assessment Focus |
|---|---|---|---|
| Acute care | Chief complaint, pain, symptom changes | Vital signs, labs, assessment findings, I&O | Clinical stability, response to treatment |
| Primary care | HPI, medication review, wellness concerns | Physical exam, screening results, growth data | Differential diagnosis, chronic disease management |
| Psychiatric / mental health | Mood, thought content, stressors, sleep, substance use | Mental status exam (MSE), affect, behavior, speech | Diagnostic formulation, safety assessment, treatment response |
| Community health | Social determinants, living conditions, access to care | Environmental assessment, screening data, community resources | Population health needs, social risk factors |
SOAP is the dominant format in nursing education, but several alternatives exist. Understanding the differences helps you choose the correct format for your program:
| Format | Components | Common Use |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | Nursing education, primary care, acute care. The most widely taught format. |
| DAP | Data, Assessment, Plan | Behavioral health and counseling settings. |
| SBAR | Situation, Background, Assessment, Recommendation | Handoff communication and rapid clinical reporting. Adapted for healthcare by Kaiser Permanente (2003). |
| BIRP | Behavior, Intervention, Response, Plan | Mental health and substance use treatment documentation. |
| GIRP | Goals, Intervention, Response, Plan | Therapy and rehabilitation documentation. |
If your program specifies a format other than SOAP, tell us in the enquiry and we will follow your required format exactly.
These are the issues that most frequently cost marks on SOAP note projects:
Mixing subjective and objective data. Patient-reported symptoms (subjective) and clinical measurements (objective) must stay in their respective sections. "Patient reports pain of 7/10" is subjective. "NRS pain score 7/10 documented by nurse" is objective.
Vague assessment. The assessment section requires clinical reasoning, not a summary. "Patient is doing well" is not an assessment. "Patient's oxygen saturation has improved from 88% to 95% on 2L nasal cannula, suggesting effective response to supplemental oxygen therapy" demonstrates clinical judgment.
Incomplete plan. A plan that says "continue current treatment" without specifying what that treatment includes, when the patient will be reassessed, and what outcomes are being monitored is incomplete.
Missing follow-up. Every plan should include a follow-up component: when the patient will be seen again, what parameters will be monitored, and what conditions would trigger earlier reassessment.
Not matching the clinical setting. A psychiatric SOAP note requires a mental status examination in the objective section. An acute care SOAP note requires vital signs and lab results. Using a generic format that ignores the setting loses marks for clinical accuracy.
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Many nursing programs now use virtual simulation platforms such as Shadow Health for clinical documentation practice. These platforms require SOAP-formatted documentation following the same standards as clinical site documentation. If your SOAP note project is based on a Shadow Health simulation or another virtual platform scenario, include the platform name and scenario details in your enquiry and we will format the documentation to match.
A SOAP note is a structured clinical documentation format with four sections: Subjective (what the patient reports), Objective (measurable clinical findings), Assessment (clinical interpretation connecting S and O), and Plan (next steps in care). Developed by Dr. Lawrence Weed in the 1960s, SOAP notes are the standard documentation format taught in BSN, MSN, and DNP nursing programs and used in clinical practice to communicate patient status across the interdisciplinary team.
The length depends on the complexity of the clinical encounter and your program's requirements. A focused single-problem SOAP note may be 1 to 2 pages. A comprehensive SOAP note covering multiple problems or a complex patient encounter may be 3 to 5 pages. Follow your rubric's length requirements exactly. Concision is valued in clinical documentation: every sentence should contribute to the clinical picture.
SOAP (Subjective, Objective, Assessment, Plan) is a documentation format for recording a complete patient encounter. SBAR (Situation, Background, Assessment, Recommendation) is a communication tool designed for rapid verbal handoffs and clinical reporting. SOAP documents an encounter in detail. SBAR summarizes it for quick communication. Most nursing programs teach both, but they serve different purposes.
Yes. Psychiatric SOAP notes require specific content: mental status examination (MSE) in the objective section, diagnostic formulation using DSM-5 criteria in the assessment, and treatment planning including medication management, therapy referrals, and safety planning in the plan. Tell us the psychiatric setting and we format the SOAP note accordingly.
Yes. Many nursing programs use Shadow Health virtual simulation for clinical documentation practice. Provide the scenario details and platform requirements in your enquiry. We format the SOAP note to match the Shadow Health documentation standards and your program's rubric.
A standard SOAP note typically takes 2 to 4 days. Complex SOAP notes (multiple problems, psychiatric settings, or advanced practice documentation) take 3 to 5 days. Express timelines are available.
Describe your project and a PhD specialist will reply with an itemized quote within 2-4 business hours. No signup, no payment, no obligation.
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