SOAP Notes for Nursing: Format, Examples and Documentation Tips

SOAP nursing notes organize an entry into Subjective, Objective, Assessment and Plan: what the patient reports, what the nurse observes, what those findings mean for nursing care and what happens next. A useful note also makes completed care and the patient’s response visible. A plan to help, teach or reassess is not a record that it happened.

This guide works through four original fictional nursing examples, including one event written as both SOAP and SOAPIE and a symptom-assessment case with escalation and reassessment. Each starts with supplied facts so you can see where every statement comes from. The focus is the nursing note itself: organizing information, expressing nursing judgment and keeping care, response and follow-up connected.

What goes in each SOAP nursing section?

SOAP organizes a note into four sections. Other formats include SOAPIE, DAR, narrative notes and a flowsheet with a focused narrative. The Open RN nursing textbook’s documentation chapter explains SOAPIE alongside those alternatives.

S: Subjective information

Use S for the patient’s account: symptoms, experiences, concerns, priorities and preferences. Attribute information supplied by a family member or other source. A patient-reported rating of 4/10 remains subjective even though it is a number.

Compare “Patient says, ‘I cannot open the toothpaste with this hand’” with “Patient unable to complete hygiene.” The first preserves the particular problem. The second expands it into a broad conclusion before the nurse has described what the patient can do. Keep a quotation when its exact wording matters; use an attributed paraphrase when it does not.

O: Objective information

Use O for relevant observations and measurements, with their time and source. In a self-care note, that might mean observing the patient wash their face after supplies are placed within reach. It does not mean adding a normal examination to make the section look complete.

Be precise about how information was obtained. “Temperature 37.1°C at 09:00 in the observation flowsheet” differs from “Patient reports feeling feverish overnight.” One is a recorded measurement; the other is an account of an earlier experience. If you did not collect a value yourself, preserve the source rather than implying that you did.

A: Nursing assessment and interpretation

A answers: What do these findings mean for the nursing concern being addressed? It might identify a need for assistance, a learning need, progress toward a goal or a concern requiring further assessment. It should connect to S and O.

The ANA description of the nursing process distinguishes information gathering, nursing judgment, planning, implementation and evaluation. This explains a common terminology trap: “assessment” in the nursing process includes collecting information, whereas A in SOAP is the interpretation of information already organized under S and O.

Describe the nursing concern supported by the findings and retain uncertainty about its cause. Nursing authority varies by designation and jurisdiction. In U.S. practice, NCSBN explains how state and territorial nursing laws define that scope.

P: Planned next steps

P links the interpretation to the next action and goal. Make the person responsible, timing or trigger, patient discussion and outstanding work understandable. “Continue care” gives the next reader little to act on.

For the fictional self-care case below, “Avery to offer assistance with remaining back care at 10:00, as agreed with the patient” identifies the pending activity, its owner and the agreed time.

SOAP vs SOAPIE: where care and response go

SOAPIE adds Implementation/Interventions and Evaluation. The Toronto Metropolitan University documentation text distinguishes intended interventions from those carried out, and links evaluation to the response. That distinction matters more than fitting every sentence under a particular letter.

In a four-field SOAP form, use the organization’s convention for recording completed interventions and response. Label them explicitly and give their times. Where SOAPIE is supported, I and E provide dedicated locations. Record observed responses separately from expected results.

For formats across professions, see the general SOAP note guide. For shifts, escalation and the broader nursing record, use the nursing-notes guide.

Example 1: assistance with personal care

Supplied facts: SN-01

This fictional event occurs on October 7, 2026. Avery Lane, RN, is the assigned nurse. The source packet supplies the facts for a focused personal-care entry.

• At 09:00, the patient says, “I can wash my face, but I need help opening the toothpaste and washing my back.”
• Avery observes a brace on the right wrist. The patient uses the left hand to handle the washcloth but cannot open the toothpaste cap during the observed attempt.
• The supplied nursing interpretation is that this activity requires setup assistance and help with the parts the patient cannot reach; it does not establish dependence for all daily activities.
• At 09:05, Avery places the requested supplies within reach and opens the toothpaste. The patient then washes their face and brushes their teeth independently with the setup provided.
• The patient asks to rest before back care. Avery and the patient agree that Avery will return at 10:00 to offer that assistance.
• At 09:15, the patient says, “That part is done; I still want help with my back later.” The 10:00 care has not occurred when Avery enters the note at 09:20.

Finished SOAP entry at 09:20

October 7, 2026 — care 09:00–09:15; entered 09:20. Avery Lane, RN.

S: Patient requests help opening toothpaste and washing back; states able to wash face. Requests rest before back care.

O: Right wrist brace observed. Uses left hand for washcloth; unable to open toothpaste cap during observed attempt. Following setup, observed washing face and brushing teeth independently.

A: Setup assistance and help with back care needed for this personal-care activity. Face washing and oral care completed with setup; back care remains outstanding.

P: Avery to return at 10:00 to offer back-care assistance, as agreed with patient.

Completed care/response: 09:05, supplies placed within reach and toothpaste opened. At 09:15, patient confirms face/oral care complete and requests back assistance later.

The completed-care line is distinct from P. It preserves the action and response within a four-field workflow; its EHR placement follows the local form. Every finding in the note traces back to the supplied facts.

The same event in SOAPIE

S and O retain the patient’s account and observed ability. A retains the focused self-care need. P retains the agreed 10:00 offer. With separate I/E fields, the action and response become:

I, 09:05: Placed requested supplies within reach and opened toothpaste.

E, 09:15: Face/oral-care portion completed; patient confirms remaining back-care request. Goal partly met; agreed 10:00 assistance remains pending.

Both layouts describe the same event. Choose the layout used by your documentation workflow.

Later source and update

The additional fictional source now supplies: at 10:00 the patient accepts back care; Avery washes and dries the patient’s back; at 10:05 the patient reports the requested care is complete. Setup assistance remains in the care plan for the next personal-care activity. Avery records the update at 10:10.

10:10 entry for 10:00–10:05 care, Avery Lane, RN: Patient accepted back-care assistance at 10:00; back washed and dried. At 10:05, patient reported requested personal care complete. Earlier back-care task completed. Setup assistance remains in the care plan for the next personal-care activity.

Keep the original 09:20 note and the later update in sequence. Completion at 10:05 should not make the earlier record look as though all care had already occurred at 09:15. In the corresponding structured record, face/oral care can be complete at the earlier time while back care is still pending. The POC charting guide develops that fields-versus-narrative check.

Example 2: care declined and an alternative completed

Supplied facts: SN-02

At 14:00 on October 7, 2026, fictional nurse Robin Shah, RN, offers the scheduled shower. The patient says, “I do not want a shower today; I would like to wash at the basin.” Robin discusses the available assistance; the patient chooses basin washing and accepts help setting up supplies. Robin provides the supplies and setup assistance. At 14:15, Robin observes the patient complete that activity. The supplied assessment identifies a preference for an alternative method, not refusal of all personal care. The agreed plan is for the next morning’s assigned nurse to offer the usual choice again; Robin will include that request in handoff. Robin enters the note at 14:20.

October 7, 2026, 14:20; Robin Shah, RN.

S: Patient declines today’s shower and requests basin washing.

O: Basin washing completed at 14:15 after setup assistance.

A: Personal-care activity completed using the patient’s chosen alternative; shower not performed.

P: Next morning’s assigned nurse to offer choice again with personal care. Robin to include request and preference in handoff.

Completed care/response: Discussed available assistance and provided basin-washing supplies. Patient accepted setup and completed the chosen activity.

“Refused hygiene” would erase the care that occurred. “Shower completed” would claim a different activity. The structured record should show shower declined and basin wash completed, where those fields exist. A global completion checkbox needs examination if it implies that every scheduled task was performed.

BCCNM’s declined-care learning example supports recording the person’s decision and reason, relevant assessment and actions, communication and follow-up. Describe the discussion that actually took place, including the assistance offered and the patient’s choice.

Example 3: teaching with an observed result

Supplied facts: SN-03

At 16:00 on October 7, 2026, the patient tells fictional nurse Casey Reed, RN, “I cannot tell which button calls you.” The existing care plan says to call for assistance before transferring. Casey asks the patient to show the call control; the patient points to the light switch. Casey’s supplied assessment is that the patient needs help distinguishing the controls.

At 16:05, Casey identifies and demonstrates the call button. At 16:10, the patient presses the correct button, the call indicator activates, and the patient states they will call before a transfer. The plan is for Casey to confirm use again before the next planned assisted transfer and include the teaching status in handoff. Casey enters the note at 16:15.

October 7, 2026 — care 16:00–16:10; entered 16:15. Casey Reed, RN.

S: At 16:00, patient reports being unable to identify the call button.

O: At 16:00, points to light switch when asked to show the call control.

A: Needs teaching to distinguish call control from light switch.

P: Casey to confirm use before next planned assisted transfer and include status in handoff.

I, 16:05: Identified and demonstrated call button.

E, 16:10: Patient pressed correct button and call indicator activated; stated intention to call before transfer. Immediate demonstration successful; future use not yet observed.

The result supports a specific conclusion: the patient demonstrated this action at this time. It does not establish understanding of every safety instruction or reliable use for the rest of the shift. “Education given; understands” is both less useful and broader than the evidence.

Example 4: dizziness, escalation and reassessment

Supplied facts: SN-04

This fictional inpatient encounter shows symptom assessment, escalation and reassessment. Its source packet supplies the care decisions and follow-up times.

On October 7, 2026, Morgan Vale, RN, is assisting a patient from the bedside toward a chair. The source packet supplies the following events; Morgan enters the note at 13:20.

• 13:00 — symptom and immediate care. On standing, the patient says, “I feel dizzy; this is new.” Morgan observes the patient sway and reach for the bed rail. Morgan stops the transfer, assists the patient back to sitting on the bed and stays with them. The chair transfer is not completed.
• 13:03 — focused findings. Seated assessment: blood pressure 122/74 mmHg, pulse 88/min and respiratory rate 18/min. The patient is alert and conversing, reports that dizziness remains while seated, and states they did not lose consciousness.
• 13:04 — nursing interpretation and escalation. Morgan's supplied nursing interpretation is that new dizziness with observed unsteadiness makes the attempted transfer unsafe to continue. The cause has not been established. Morgan telephones Elena Moss, MD, the covering physician, and reports the onset, observed unsteadiness, seated findings and stopped transfer.
• 13:07 — actual clinician response. Dr. Moss assesses the patient at the bedside. Morgan records the physician's response: defer another transfer attempt pending review; Morgan to reassess symptoms and seated observations at 13:15 and 13:30, and notify Dr. Moss immediately if symptoms worsen or recur after settling. No diagnosis or medication order is supplied in this packet.
• 13:15 — reassessment. The patient reports that dizziness has settled while sitting. Morgan records seated blood pressure 124/76 mmHg, pulse 84/min and respiratory rate 16/min; the patient remains alert and conversing. Standing and transfer tolerance have not been reassessed.

Finished SOAPIE entry at 13:20

October 7, 2026 — events 13:00–13:15; entered 13:20. Morgan Vale, RN.

S: At 13:00, patient reports new dizziness on standing. At 13:03, reports dizziness continuing while seated and no loss of consciousness.

O: At 13:00, swayed and reached for bed rail during assisted transfer attempt. At 13:03, seated BP 122/74 mmHg, pulse 88/min, RR 18/min; alert and conversing.

A: New dizziness with observed unsteadiness prevents safe completion of the attempted transfer. Cause not established. Symptom improvement while seated does not establish tolerance of standing or transfer.

P: Per Elena Moss, MD, following bedside assessment at 13:07, defer another transfer attempt pending review. Morgan to repeat symptom assessment and seated observations at 13:30; notify Dr. Moss immediately if symptoms worsen or recur after settling.

I: At 13:00, stopped transfer, assisted patient back to sitting on bed and remained with patient. At 13:04, telephoned Dr. Moss with symptom onset, unsteadiness, seated findings and stopped transfer. Dr. Moss assessed patient at 13:07 and requested reassessment at 13:15 and 13:30, with earlier notification for worsening or recurring symptoms. Completed the first reassessment at 13:15.

E, 13:15: Patient reports dizziness settled while sitting. Seated BP 124/76 mmHg, pulse 84/min, RR 16/min; alert and conversing. Chair transfer remains incomplete; standing/transfer tolerance not reassessed. The 13:30 reassessment and subsequent review remain pending.

Why the Assessment is supported

The interpretation connects reported new dizziness with observed unsteadiness and an immediate nursing-care decision: stop this transfer and seek review. It does not convert those facts into “dehydration,” “orthostatic hypotension” or another cause that the source does not establish. Likewise, the evaluation describes improvement in one position at one time, rather than claiming the patient is now safe to walk independently.

The communication trail also separates a call from a response: 13:04 report to a named physician → 13:07 bedside assessment and instructions → 13:15 completed reassessment → 13:30 owned, pending task. In British Columbia, BCCNM's documentation standard, items 3, 4 and 8, addresses the decision-making process, chronological care information and the identity and response of the professional receiving an escalated concern.

Check the related records against the same facts: the chair-transfer task is not completed, the 13:15 observations are recorded with their seated position, and Morgan still owns the 13:30 reassessment. “Physician aware; dizziness resolved; transfer complete” would lose the actual response, overstate the reassessment and falsely close unfinished care.

How to write the note without losing the sequence

Start from the event, not a prefilled paragraph. Identify the relevant patient account, observed findings, nursing interpretation, actual care and remaining work. Sort those into headings after the facts are clear. This avoids letting an empty box tempt you to invent a finding.

1. Confirm context. Open the correct patient and encounter. Identify why this focused entry is needed and the event time.
2. Separate sources. Keep the patient’s report apart from your observations and information from another person or record.
3. State the nursing meaning. Connect A to those findings. In SN-01, assistance is needed for particular tasks; the note does not generalize to total dependence.
4. Separate action states. Check each verb: offered, agreed, requested, completed, declined and reassessed describe different events.
5. Read the saved record. Compare the note with the relevant flowsheet, task or care-plan entry, then authenticate through the documentation workflow.

The CNO Documentation standard, effective February 1, 2026, addresses communication, documentation requirements and information security for Ontario nurses. It calls for an attributable, timely record of nursing care and decisions. If an entry is late, distinguish its entry time from the event time. Corrections need to retain the original information rather than silently rewriting the chronology.

If the event includes escalation, document the actual recipient, time, information sent and response. “Provider aware” cannot show whether a message was merely sent, acknowledged or acted on. BCCNM’s current standard, item 8, specifically addresses recording escalated concerns and the receiving professional’s identity and response.

A quality checklist for SOAP nursing notes

Use these eight source-linked checks to identify specific documentation defects. Review and resolve each finding individually.

1. Correct context: Is the entry tied to the intended patient, event, date/time and author?

   CNO documentation requirements

   .

2. Attributable facts: Can the reader distinguish reported information from observations?

   NSCN documentation guidelines

   .

3. Supported interpretation: Does A follow from the findings and stay within the writer’s role?

   ANA nursing process

   .

4. Visible action states: Are intended interventions separate from those completed?

   TMU methods of documentation

   .

5. Specific response: Does evaluation say what changed, what was observed and what remains open? Open RN SOAPIE explanation.

6. Patient choice: Are preferences and declined activities represented without assumptions or judgmental labels?

   BCCNM declined-care guidance

   .

7. Follow-up and communication: Are the next action and responsible person clear, with actual communication outcomes?

   BCCNM standards 3–8

   .

8. Consistent record: Do the note and related fields agree, with corrections traceable?

   NSCN documentation guidelines

   .

Applied to SN-01 at 09:20, a draft saying “all personal care completed independently” fails in two ways. It adds unsupported independence and loses the pending back-care request. Repair the sentence to describe setup assistance and completed face/oral care; restore Avery’s 10:00 task. Then check the structured fields rather than assuming that repairing the prose also repaired their status.

Blank SOAP nursing template

Copy the prompts into your documentation workspace and adapt them to its fields. Add the relevant findings, nursing interpretation, completed care, patient response and next steps, then remove unused prompts.

SOAP NURSING NOTE — BLANK STRUCTURE
Context: [correct patient/encounter; reason for note; event date/time; entry date/time; author and nursing title]

S — SUBJECTIVE
[What the patient reports, requests or prefers; relevant caregiver account with attribution; exact words when useful]

O — OBJECTIVE
[What you observed or measured; time, units and source; link to the relevant flowsheet rather than duplicating an entire chart]

A — ASSESSMENT
[Nursing interpretation or priority supported by S and O; remaining uncertainty; progress toward an identified goal]

P — PLAN
[Next action; responsible person; agreed timing or trigger; patient discussion; pending communication or reassessment]

COMPLETED CARE AND RESPONSE
[Use your SOAP layout or separate I/E fields. State what actually happened, when, who did it and the patient's response. Keep future actions distinct.]
I — IMPLEMENTATION, if used: [completed care, teaching or communication, with times]
E — EVALUATION, if used: [observed/reported response, comparison with goal, unresolved need and next owned action]

FINAL RECORD CHECK
[Confirm source accuracy, action states, corresponding structured entries, saved text and authentication. Remove unused prompts.]

Using AI to organize a nursing note

AI-assisted drafting can move supplied information into SOAP headings. Review the resulting relationships, not just spelling: did the draft turn a report into an observation, a focused need into a broad diagnosis, or a planned action into completed care? SN-01 would remain wrong if a polished draft omitted the 10:00 task.

For Ontario nurses, CNO’s current standard requires informed consent when AI is used for documentation, in accordance with organizational policy. In British Columbia, BCCNM’s standards 15–16 require employer approval and AI policies, and keep the nurse accountable for reviewing the entry.

Vero publishes this guide and offers note-drafting software. The worked examples are fictional teaching cases. For a closer look at checking generated text against its source and saved destination, see the clinical notes AI guide.

For the broader role-specific product workflow, explore Vero’s nursing documentation workflow, which illustrates progress notes, DAR notes and SBAR handoffs.

Sources

Sources were checked on October 7, 2026. CNO covers Ontario, BCCNM covers British Columbia and NSCN covers Nova Scotia. ANA provides U.S. professional guidance; Open RN and TMU explain documentation formats.