50+ SOAP Note Examples, 2 Templates and Format Guide for 2024

SOAP NOTE EXAMPLES, TEMPLATES and FORMAT GUIDE

As you work on becoming a skilled healthcare professionals, one critical skill that you need to acquire is documenting patient information accurately and comprehensively. 

SOAP NOTES short for Subjective, Objective, Assessment, and Plan, are a fundamental tool in healthcare documentation.

These notes serve as a crucial communication tool among healthcare providers, ensuring continuity of care and patient safety.

In this comprehensive guide, we will delve into the intricacies of creating effective soap notes tailored for nursing students.

What are SOAP NOTES

Definition of SOAP notes

A soap note is a clinical method used by healthcare practitioners to simplify and organize a patient’s information.

Healthcare practitioners use the SOAP note format to record information in a consistent and structured way. 

Importance of SOAP notes in healthcare settings

Before delving into the specifics of creating a soap note, it’s essential to understand their purpose. Soap notes are a structured format for documenting patient information. They serve several key functions:

• Organized documentation process
• Communication: Soap notes provide a standardized method for healthcare professionals to communicate with each other about a patient’s condition, progress, and treatment plan.
• Legal Protection: They serve as a legal record of the care provided to a patient, which can be vital in case of disputes or legal issues.
• Continuity of Care: Soap notes ensure that different healthcare providers can understand and continue the patient’s care seamlessly.
• Monitoring and Evaluation: These notes enable healthcare providers to track a patient’s progress over time and adjust their treatment plan as needed.
• Facilitation of patient care continuity

Elements of SOAP Notes and How to Write them

The elements of a SOAP note are:

1. Subjective (S): focuses on the patient’s information, experience and perceptions of symptoms, needs, and progress toward treatment goals.
2. Objective (O): documents observable, objective data (“facts”) regarding the patient, like elements of a mental status exam or other screening tools, historical information, medications prescribed, x-rays results, or vital signs.
3. Assessment (A): Includes the clinician’s assessment of the available subjective and objective information. The assessment summarizes the client’s status and progress toward treatment plan goals.
4. Plan (P): Records the actions to be taken due to the clinician’s assessment of the member’s current status, such as assessments, follow‐up activities, referrals, and changes in the treatment.

SOAP Note Format Guide for 2024

Subjective Section

In the soap note subjective data section, includes what the patient tells you, but organize the information as a clinician

• Patient Initials: _____  Age: _______ Gender: ______
• Chief Complaint (CC): In just a few words, explain why the patient came to the clinic. (You can use the patients words and quote them) for instance
• History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom

1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations

• Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
• Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
• Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
• Past Surgical History (PSH): Include dates, indications, and types of operations.
• Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
• Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
• Immunization History: Include last Tdp, Flu, pneumonia, etc.
• Significant Family History: Include history of parents, Grandparents, siblings, and children.
• Lifestyle: Include cultural factors, economic factors, safety, and support systems.
• Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).

Find more examples of subjective soap notes

Objective section

In the objective section, you document measurable and observable data gathered during the physical examination or diagnostic tests. This should be concrete and based on your professional assessment. Key tips for this section include:

• Use Precise Language: Describe findings using medical terminology and avoid vague terms.
• Include Vital Signs: Record the patient’s vital signs, such as blood pressure, heart rate, respiratory rate, and temperature.
• Note Objective Findings: Document physical exam findings, laboratory results, and diagnostic test results.
• This is the measurable and observable data gathered during the physical examination or diagnostic tests.
• This should be concrete and based on your professional assessment.
• Both subjective and objective sections of the SOAP note guide the collection of data from the patient.

The documentation of objective data includes;

• General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
• HEENT
• Neck
• Breasts
• Respiratory
• Cardiovascular/Peripheral Vascular
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Psychiatric
• Neurological
• Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
• Hematologic:
• Endocrine:
• Allergic/Immunologic:

Assessment section (A)

The assessment section is where you, as the nursing student, provide your professional analysis and interpretation of the subjective and objective data. In this section:

• Identify Nursing Diagnoses: Formulate nursing diagnoses based on the data you’ve collected.
• Prioritize Problems: Determine which issues are most critical and require immediate attention.
• Include Patient Goals: Set measurable goals for the patient’s care and recovery.

• Entails analysis and interpretation of the subjective and objective data. In this section you will Identify the nursing diagnosis and differential diagnoses based on the data you’ve collected in the subjective and objective sections
• Include findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment AND include the patient’s Informed Consent Ability.

DSM5 Diagnosis: with ICD-10 codes

• Dx: –   
• Dx: –   
• Dx: –   

Patient has the ability/capacity appears to respond to psychiatric medications/psychotherapy and appears to understand the need for medications/psychotherapy and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.

Here are soap notes assessment section examples 

Plan section

The plan section outlines the healthcare provider’s intended actions for the patient’s care. It includes both short-term and long-term goals, interventions, and follow-up plans. To create an effective plan:

• Set Priorities: Arrange interventions in order of importance.
• Include Timelines: Specify when each intervention should occur.
• Involve the Patient: Consider the patient’s preferences and involve them in the decision-making process when appropriate.

The Plan section shows clinical reasoning and decision-making skills and includes; 

• Therapeutics
  • Pharmacological plan
  • non-pharmacological plan
• Educational Plan
• Referrals – Consultation/Collaboration plan
• Follow-up plan

55 SOAP Note Examples

1. Comprehensive Psychiatric Soap Note Example
2. Major Depressive Disorder Focused Soap Note Example
3. Patient With Anxiety Soap Note-A 
4. Focused Soap Note For Schizophrenia Spectrum  – Focused Soap Note For Schizophrenia Spectrum, Other Psychotic, And Medication-Induced Movement Disorders
5. Focused Soap Note For Anxiety Ptsd And Ocd  – Focused Soap Note For Anxiety PTSD And OCD
6. Major Depressive Disorder Focused Soap Note- and medical notes– 
7. Anxiety Soap Note- -Therapy soap note examples
8. Comprehensive Focused Soap Note For Schizophrenia Spectrum Other Psychotic And Medication-Induced Movement Disorders – Comprehensive Focused Soap Note For Schizophrenia Spectrum Other Psychotic And Medication-Induced Movement Disorders 
9. Comprehensive Soap Note On Generalized Anxiety Disorder 
10. Comprehensive Psychiatric Evaluation Soap Note On Obsessive-Compulsive Disorder-Nursing Essay Example
11. Major Depressive Disorder Focused Soap Note-A  
12. Patient With Anxiety Soap Note Comprehensive Nursing Paper Sample 
13. Comprehensive Soap Note On Assessing And Diagnosing Patients With Mood Disorders- 
14. Pediatric Soap Note Example
15. PMHNP Soap Note Example
16. Comprehensive ADHD Soap Note
17. Initial Psychiatric Interview Soap Note
18. Clinical Soap Note On Psychiatric Progress Note  
19. Clinical Follow-Up Soap Note For A Psychiatric Patient 
20. Soap Note For A Suicide Assessment Of A Client With Initially Subtle Warnings Of Suicide-Shelby Colatrella Case Study  
21. Moderate Alcohol Use Disorder Comprehensive Soap Note Example 
22. Clinical Soap Note On Obsessive-Compulsive Disorder  
23. Obsessive-Compulsive Disorder Comprehensive Clinical Soap Note 
24. Adjustment Disorder Soap Note 
25. Soap Note On Schizophreniform Disorder
26.  Week 7- Prac-6665 Focused Soap Note And Patient Case Presentation-
27. Soap Note On Incarcerated Hernia 
28. Clinical Soap Note For A Pediatric Patient   
29. Obsessive Compulsive Disorder Clinical Soap Note
30. Social Anxiety Clinical Soap Note 
31. Mental Health Clinical Soap Note 
32. Clinical Soap Note On Anxiety Disorder
33. Episodic Soap Note Allergic Rhinitis
34. Depression Focused Soap Note 
35. Brian Foster Soap Note 
36. Comprehensive Soap Note On Proasis 
37. Tina Jones Documentation Of History And Physical Exam Soap Note 
38. Focused Soap Note And Patient Case Presentation 
39. Borderline Personality Disorder Focused Soap Note
40. Comprehensive Soap Note On Psoriasis
41. Pediatric Comprehensive Soap Note – Well Child Exam Without Abnormalities (Z00.129)
42. Case Study Analysis Example With Soap Note – Genitourinary Assessment Soap Note
43. Tina Jones Comprehensive Soap Note
44. Unit 12 Assignment – Clinical: Soap Note
45. Initial Psychiatric Interview/Soap Note – Assignment 1 Solution
46. The Assignment 1: Focused Soap Note On Personality And Paraphilic Disorders 
47. Soap Notes For Mental Health Professional 
48. Unit 3 Soap Note – Ms. A Presents With Complaints Of Headache And General Fatigue
49. Comprehensive Psychiatric Evaluation Note soap note examples to help
50. Focused Soap Psychiatric Evaluation Comprehensive Nursing Paper Sample
51. Unit 7 Soap: 54 Yo Female With Low Back Pain Radiating To Left Leg – Solution

SOAP Notes Templates

1. Initial Psychiatric Soap Note Template
2. Shadow Health Comprehensive Soap Note Template 
3. 670 Case Study Psychiatric Soap Note Template With Rx  
4. Tina Jones Shadow Health Soap Note Template

Tips for Effective Soap Note Documentation

Creating comprehensive and accurate soap notes can be challenging, but with practice and attention to detail, nursing students can master this essential skill. Here are some tips to help you excel in soap note documentation:

1. Maintain Confidentiality – Always remember to maintain patient confidentiality. Use initials or unique identifiers instead of the patient’s full name, and store your notes securely to protect patient privacy.
2. Be Concise and Clear – Avoid unnecessary jargon or acronyms that may not be familiar to all healthcare providers. Write in a clear, concise, and organized manner to ensure your notes are easy to understand.
3. Use Standard Terminology – Adopt standardized medical terminology to ensure consistency and clarity in your documentation. This helps prevent misunderstandings among healthcare providers.
4. Follow the Nursing Process – The nursing process involves assessment, diagnosis, planning, implementation, and evaluation (ADPIE). Apply this framework when creating your soap notes to ensure a comprehensive approach to patient care.
5. Collaborate with Others – Communication is key in healthcare. Collaborate with other members of the healthcare team, such as physicians, therapists, and social workers, to gather and incorporate their input into your notes.
6. Stay Up-to-Date – Medical knowledge evolves constantly. Stay updated on the latest evidence-based practices and guidelines relevant to your field of nursing to provide the best care and documentation.