Nursing SOAP Note

This form can be used by nurses to collect patient information, documenting the results of physical observations and laboratory tests. The Subjective, Objective, Assessment and Plan (SOAP) note is a widely used method of documentation for healthcare providers.

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Nursing SOAP Note

Nursing SOAP Note

Subjective Data

Objective Data

Assessment

Plan

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Nursing SOAP Note

This form can be used by nurses to collect patient information, documenting the results of physical observations and laboratory tests. The Subjective, Objective, Assessment and Plan (SOAP) note is a widely used method of documentation for healthcare providers.

1. Chief complaint

2. History of present illness

3. History of past illness

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

5. Family History

6. Review of Systems

7. Is the patient taking any medication?

8. Does the patient have any allergies?

1. Age

2. Height (in inches)

3. Weight (in lbs)

4. BMI

5. Gender

6. General Appearance

7. Blood Pressure

8. Body temperature

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

10. Respiratory

11. Cardiovascular

12. Integument/ Lymphatic Inspection

13. Laboratory Results

1. General Observations

2. Differential Diagnosis

1. Any other notes