By North Essay Help Editorial Team ·
SOAP Note Example for Nursing Students (With Line-by-Line Rewrites)
A SOAP note has four parts: Subjective, Objective, Assessment and Plan. Most students get S and O right. Marks are lost in A and P, where the note has to show your thinking, not just your data. Below is a full example, a template you can reuse, and rewrites of the sentences instructors flag most often.
Full SOAP note example
The scenario is fictional. A 68-year-old patient is on day 1 after a right total knee replacement, seen at 0900 on a surgical unit.
S: "My knee is throbbing, about a 7 out of 10. It's worse when I try to bend it." States last pain medication "was early this morning." Reports nausea after breakfast; no vomiting. Says she is "nervous about getting up."
O: T 37.4°C, HR 96, BP 142/84, RR 18, SpO2 95% on room air. Right knee dressing dry and intact; mild swelling around the knee; toes warm, pink, capillary refill under 3 seconds; able to wiggle toes; reports normal sensation. Grimaces on knee flexion; flexion limited to about 40 degrees. Last analgesic given at 0500 (per MAR). Ate 25% of breakfast. Has not walked since surgery.
A: Acute post-operative pain, not adequately controlled (7/10, 4 hours after last dose), limiting mobility and range of motion. Nausea may be linked to analgesic or reduced intake. Neurovascular status of right leg intact. Raised heart rate likely related to pain; temperature within expected range for day 1 after surgery but to be monitored. At risk for falls and for complications of immobility.
P: Give prescribed analgesic now and reassess pain in 30 to 60 minutes; offer prescribed antiemetic 30 minutes before meals. Cold therapy to right knee per order. Physiotherapy-assisted walk with walker this morning, once pain is 4/10 or lower; two-person assist, non-slip socks, call bell within reach. Neurovascular checks every 4 hours. Encourage fluids and small meals. Goal: pain 4/10 or lower and walking to the bathroom with walker by end of shift. Report temperature above 38.0°C or new calf pain to the charge nurse.
Notice what the Assessment does: it names the problem, links the data to it ("4 hours after last dose", "limiting mobility"), and flags risk. The Plan then answers each point in the Assessment, with a time and a measurable goal.
What goes in each section
| Section | What it is | What belongs here | What does not |
|---|---|---|---|
| S: Subjective | What the patient (or family) tells you | Direct quotes, symptoms in their words, pain rating they give, history they report | Your interpretation ("patient seems anxious") |
| O: Objective | What you observe, measure or read | Vital signs, assessment findings, lab values, intake and output, what you see on the MAR or chart | Opinions, words like "good", "normal" or "fine" without numbers |
| A: Assessment | Your clinical judgment | The main problem, what the data means, change since last note, risks | New data, or a repeat of S and O |
| P: Plan | What happens next | Interventions with timing, who does them, reassessment, measurable goals, when to escalate | Vague intentions ("monitor patient") |
Fill-in template
Copy this and fill each line.
S:
- Chief concern in the patient's words: "..."
- Symptom details (onset, location, rating, what makes it better or worse): ...
- Relevant history the patient reports: ...
O:
- Vital signs (with units): T ..., HR ..., BP ..., RR ..., SpO2 ...
- Focused assessment for the problem: ...
- Relevant labs, tests, intake and output, medications given (with times): ...
A:
- Main problem (nursing diagnosis or clinical problem): ...
- What the data shows (link at least two findings to the problem): ...
- Change since last assessment (better, worse, same): ...
- Risks to watch: ...
P:
- Interventions, each with a time or frequency: ...
- Reassessment (what, when): ...
- Measurable goal with a time frame: ...
- When and to whom to escalate: ...
Rewrites of common mistakes
These are the sentences that cost marks, with stronger versions.
| Weak | Why it loses marks | Stronger |
|---|---|---|
| S: "Patient is in pain." | Not the patient's words; no detail | S: "My knee is throbbing, about a 7." Worse on bending. |
| O: "Vitals stable." | No numbers, so nobody can compare later | O: T 37.4°C, HR 96, BP 142/84, RR 18, SpO2 95% RA. |
| O: "Patient anxious." | An interpretation, not an observation | O: Asked three times about getting up; hands trembling. |
| A: "Pain 7/10, HR 96." | Repeats data instead of interpreting it | A: Post-op pain not controlled, raising HR and limiting mobility. |
| A: "Patient doing well." | No problem, no judgment | A: Neurovascular status intact; pain control is the priority problem. |
| P: "Monitor patient." | No action, time or measure | P: Reassess pain 30 to 60 min after analgesic; goal 4/10 or lower by 1200. |
| P: "Encourage ambulation." | No conditions or safety steps | P: Walk with walker and two-person assist once pain is 4/10 or lower. |
SOAP vs SOAPIE, DAR and PIE
Your placement or program may ask for a different format. They record the same thinking in a different order.
| Format | Parts | Where you'll see it |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | Clinical courses, primary care, most student assignments |
| SOAPIE (or SOAPIER) | SOAP plus Intervention, Evaluation (and Revision) | Courses that want you to show what you did and whether it worked |
| DAR (Focus charting) | Data, Action, Response, written under a focus heading | Many Canadian and U.S. hospital units |
| PIE | Problem, Intervention, Evaluation | Some acute care settings; pairs with a separate assessment flow sheet |
To turn the example above into SOAPIE, add:
I: 0915 hydromorphone given as prescribed; ice pack applied to right knee; antiemetic given 0915.
E: 1000 pain 3/10; walked 10 metres with walker and two-person assist; no nausea.
Charting rules that apply to every note
These come from nursing documentation standards. In Ontario, the College of Nurses of Ontario's revised Documentation practice standard took effect on February 1, 2026, and adds expectations on technology, including AI tools.
- Document after care, never before. If you chart late, label it a late entry and note the time care was given.
- Use only approved abbreviations. If your organization has no approved list, write terms out in full.
- Keep S and O separate. Subjective is what the client says; objective is what you observe or measure.
- Say who did what. If another provider did an assessment or intervention, make that clear.
- No identifying details in assignments. Remove names, initials, room numbers and exact dates from any note you submit for school.
Frequently asked questions
What is a SOAP note in nursing?
A structured way to document a patient encounter in four parts: what the patient reports (Subjective), what you observe and measure (Objective), your clinical judgment (Assessment) and what happens next (Plan). The format comes from the problem-oriented medical record developed by Dr. Lawrence Weed in the late 1960s.
How long should a SOAP note be?
Long enough to support your Assessment and Plan, and no longer. For a single focused problem, a student SOAP note is usually 150 to 300 words. Assignments may set their own length.
Is pain rating subjective or objective?
The rating the patient gives you ("7 out of 10") is subjective. Behaviour you observe (grimacing, guarding, limited range of motion) is objective. Record both.
What is the difference between Assessment and Objective?
Objective is the data. Assessment is what the data means. If your Assessment could be copied from your Objective section, rewrite it as a judgment: name the problem and link the findings to it.
Can I write a nursing diagnosis in the Assessment?
Yes. Many programs expect a nursing diagnosis or clinical problem statement there, supported by the data in S and O.
What is the difference between SOAP and SOAPIE?
SOAPIE adds Intervention (what you did) and Evaluation (how the patient responded). Use it when your instructor wants to see the outcome of your care, not only the plan.
Related guides and tools
- How to write a nursing care plan
- Digital nursing portfolio: examples and structure
- Nursing assignment help
- Gibbs reflective cycle nursing example
- SBAR examples for nursing students
- PICO question examples for nursing
- How to write nursing interventions
Sources: College of Nurses of Ontario, Documentation practice standard (revised, effective February 1, 2026); Toronto Metropolitan University, Documentation in Nursing (1st Canadian edition, open textbook); Weed, L. L. (1968), Medical records that guide and teach, New England Journal of Medicine. The example is fictional and for learning only; always follow your program's and placement's documentation policies.
