Nursing Soap Note

Updated: over a week ago

Nursing SOAP Note

Subjective Data

1. Chief complaint


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2. History of present illness


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3. History of past illness


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4. Social History (e.g., does the patient smoke/ do enough sports, etc.)


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5. Family History


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6. Review of Systems


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7. Is the patient taking any medication?


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8. Does the patient have any allergies?


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Objective Data

2. Height (in inches)


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3. Weight (in lbs)


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6. General Appearance


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7. Blood Pressure


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8. Body temperature


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9. Any different appearances regarding eyes, ears, nose, throat?


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10. Respiratory


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11. Cardiovascular


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12. Integument/ Lymphatic Inspection


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13. Laboratory Results


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Assessment

1. General Observations


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2. Differential Diagnosis


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Plan

1. Any other notes


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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