Question · Clinical documentation

What is a SOAP note in nursing?

Short answer

A SOAP note documents a patient encounter in four sections: Subjective (what the patient reports), Objective (measurable findings such as vital signs and exam results), Assessment (your clinical judgment or diagnoses) and Plan (treatment, education and follow-up). Nurses and nurse practitioners use it so every reader finds the same information in the same place.

A clinician with a stethoscope checking a patient's blood pressure

Answer and explanation

SOAP notes keep documentation consistent, so every reader finds the same information in the same place.

The four sections

Subjective: what the patient tells you, ideally in their own words.
Objective: what you observe and measure, such as vital signs and exam findings.
Assessment: your interpretation, such as a nursing diagnosis.
Plan: treatment, tests, education and follow-up.

A short example

S: "My chest feels tight when I climb stairs." Two weeks, relieved by rest.
O: BP 148/92, HR 88, SpO2 97% on room air, lungs clear.
A: Exertional chest pain; rule out stable angina.
P: ECG, cardiac referral, and teaching to call 911 for chest pain at rest.

Updated October 13, 2026