A nurse practitioner SOAP note documents an episodic visit the way NP programs and preceptors expect: pertinent positives and negatives, a justified differential, and a complete plan. Copy the free template, see a urinary tract infection and an ear infection example, and check what goes in each part.
Blank nurse practitioner SOAP note template
FreeNURSE PRACTITIONER SOAP NOTE Patient: [Name] Date of birth: [Date] Date of visit: [Date] Source of history: [Patient, parent, or caregiver, and how reliable] Nurse practitioner: [Name, credentials] SUBJECTIVE Chief complaint: [In the patient's words] History of present illness: [Onset, location, duration, character, aggravating and relieving factors, radiation, timing, severity] Pertinent positives: [Symptoms present that support the leading diagnosis] Pertinent negatives: [Symptoms absent that make other diagnoses and red flags less likely] Past medical history: [Conditions, surgeries, hospital stays] Medications: [Prescription, over-the-counter, and supplements, with doses] Allergies: [Drug, food, and other allergies, with the reaction to each] Social history: [Tobacco, alcohol, substances, work, living situation, and sexual history if relevant] Review of systems: [Systems reviewed, with pertinent findings] OBJECTIVE Vital signs: [BP, HR, RR, temperature, SpO2, weight] Focused examination: [General appearance and the systems related to the complaint] Point-of-care tests: [Urine dipstick, rapid tests, pregnancy test, or glucose, with results] ASSESSMENT Primary diagnosis: [Diagnosis, with the history and exam findings that support it] Differential 1: [Alternative diagnosis, and why it is more or less likely] Differential 2: [Alternative diagnosis, and why it is more or less likely] Differential 3: [Alternative diagnosis, and why it is more or less likely] PLAN Diagnostics: [Labs, cultures, or imaging ordered and why, or why none are needed] Therapeutics: [Medications and non-drug treatment, and the guideline followed] Education: [What was taught, and the patient's understanding] Referral or consultation: [Collaborating physician, specialist, or other service, if any] Follow-up: [When to return, and the warning signs that mean returning sooner] PRESCRIBING DETAILS Prescription: [Drug, strength, dose, route, frequency, duration, quantity, and refills] Checks: [Allergies, interactions, pregnancy or lactation, kidney function, and weight-based dosing reviewed] Signed: [Nurse practitioner name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care, same-day visit
Chief complaint: “It burns when I pee.” 27-year-old woman with painful urination, frequency, and urgency for 2 days, and mild pressure above the pubic bone. Pertinent positives: dysuria, frequency, urgency, suprapubic discomfort. Pertinent negatives: no fever, chills, flank or back pain, nausea, or vomiting; no vaginal discharge, itching, or odor; no new sexual partner; no urinary infection in the past year. Last menstrual period 2 weeks ago. No medical conditions or regular medications. Allergy: sulfonamide antibiotics, hives. One long-term male partner; nonsmoker.
T 36.8 °C (98.2 °F), HR 78, BP 116/74, RR 14, weight 62 kg (137 lb). Well appearing. Abdomen soft, mild suprapubic tenderness, no costovertebral angle tenderness on either side. Pelvic exam not done: no vaginal symptoms. Urine dipstick: leukocyte esterase 2+, nitrite positive, trace blood. Urine pregnancy test negative.
Primary diagnosis: acute uncomplicated cystitis. Dysuria, frequency, and urgency without vaginal symptoms, with leukocytes and nitrite on the dipstick; not pregnant, no known urinary tract abnormality, no systemic signs. Differential 1: pyelonephritis, less likely: no fever, flank pain, nausea, or costovertebral angle tenderness. Differential 2: vaginitis, less likely: no discharge, itching, or odor. Differential 3: urethritis from a sexually transmitted infection, less likely with one long-term partner and no discharge; test if symptoms persist.
Diagnostics: urine culture not sent for a first uncomplicated episode; send one if symptoms persist after 48 to 72 hours of treatment or come back within 4 weeks. Therapeutics: nitrofurantoin for 5 days, a first-line choice in current guidelines; trimethoprim-sulfamethoxazole avoided because of her sulfonamide allergy. Fluids, and acetaminophen or ibuprofen for discomfort. Education: take with food; urine may turn dark yellow or brown; finish the course. Referral: none. Follow-up: call if not improving within 48 hours; seek care the same day for fever, back or flank pain, or vomiting.
Prescription: nitrofurantoin monohydrate/macrocrystals 100 mg capsules, 1 capsule by mouth twice daily with food for 5 days; quantity 10; no refills. Checks: sulfonamide allergy noted; no interacting medications; pregnancy test negative and not breastfeeding; no known kidney disease.
Primary care, same-day visit with a parent
Source of history: his father, reliable. Chief complaint: “He’s been pulling at his right ear since yesterday.” 4-year-old boy with right ear pain for 1 day, after 3 days of a runny nose. Fever to 38.3 °C (100.9 °F) at home last night. Pertinent positives: ear pain, fever, cold symptoms, fussiness. Pertinent negatives: no ear discharge, vomiting, rash, or neck stiffness; drinking and passing urine normally. No ear infection in the past 6 months; no ear tubes. Otherwise healthy; immunizations up to date. Medications: one dose of acetaminophen last night. Allergies: none known. Attends daycare.
T 38.1 °C (100.6 °F), HR 112, RR 22, SpO2 99%, weight 16 kg (35 lb). Alert, and playful between bouts of discomfort. Right eardrum red, bulging, and opaque, with reduced movement on pneumatic otoscopy; no discharge. Left eardrum normal. Ear canals normal; no pain on moving the outer ear. No swelling, redness, or tenderness behind either ear. Throat mildly red, no exudate. Clear nasal discharge. Neck supple. Chest clear.
Primary diagnosis: acute otitis media, right ear, non-severe: bulging eardrum with ear pain and fever of recent onset; mild pain for under 48 hours; temperature below 39 °C (102.2 °F). Differential 1: otitis media with effusion, less likely given the acute pain, fever, and bulging. Differential 2: otitis externa, unlikely: normal canal, no pain on moving the outer ear. Differential 3: mastoiditis, unlikely: no swelling, redness, or tenderness behind the ear. Concurrent viral upper respiratory infection.
Diagnostics: none needed. Therapeutics: observation without antibiotics, an option in current guidance for an otherwise healthy child 2 years or older with non-severe acute otitis media in one ear when follow-up is assured; chosen with his father after discussing starting antibiotics now instead. Pain relief is the priority. If he isn’t improving within 48 to 72 hours, or is worse sooner, start high-dose amoxicillin, 80 to 90 mg/kg/day divided twice daily. Education: expected course, pain relief by weight, fluids. Referral: none. Follow-up: clinic nurse to phone in 48 hours; same-day visit if not improving. Seek care at once for a stiff neck, swelling or redness behind the ear, unusual drowsiness, or fever of 39 °C (102.2 °F) or higher.
Prescription: no antibiotic today. Pain relief by weight, 16 kg (35 lb): ibuprofen 160 mg (8 mL of 100 mg/5 mL) by mouth every 6 to 8 hours as needed, or acetaminophen 240 mg (7.5 mL of 160 mg/5 mL) by mouth every 4 to 6 hours as needed, no more than 5 doses in 24 hours. Checks: no drug allergies; weight measured today; doses shown to his father with an oral syringe.
The history, organized so a reader can follow your reasoning: the story, then the positives and negatives that point toward or away from each diagnosis.
Avoid: Pasting a full review of systems without pulling out the findings that matter.
A focused exam that matches the complaint, with vital signs and any bedside tests.
Avoid: Examining unrelated systems while missing the one that rules out the serious diagnosis.
Your leading diagnosis and the alternatives, each tied to the evidence for and against it.
Avoid: Listing differentials with no reason for ranking them.
An evidence-based plan in five parts, so nothing is skipped.
Avoid: Writing “return if worse” in place of the warning signs for this diagnosis.
Everything a pharmacist or the next clinician needs to check the prescription.
Avoid: Writing “antibiotic as prescribed” instead of the drug, dose, and duration.
Choose pertinent negatives that address the serious alternatives, like fever and flank pain for pyelonephritis, rather than a list of unrelated systems.
Say why you chose the drug: first-line guidance, an allergy, local resistance, or a previous response. Preceptors and reviewers look for it.
For some infections, such as non-severe acute otitis media, observation is a guideline option. Record the criteria you checked and the shared decision, whichever way you go.
Record today’s weight and the mg/kg dose for every pediatric prescription, so the calculation can be checked.
Watchful waiting is only safe with follow-up. Record who will check in, when, and what happens if the patient isn’t better.
Vero Scribe writes the SOAP note in your template from the visit conversation, with the patient’s consent, or from your dictation. You check the differential and the prescribing details, edit anything, and copy the note into your EHR.
A focused history with pertinent positives and negatives, an exam that matches the complaint, a differential with reasons, and an evidence-based plan with complete prescribing details, education, and follow-up.
Usually two or three, chosen to cover the most likely and the most dangerous alternatives. For each, note the findings that make it more or less likely.
Pertinent positives are findings present that support a diagnosis. Pertinent negatives are findings you checked for and didn’t find, which make other diagnoses, especially serious ones, less likely.
The drug, strength, dose, route, frequency, duration, quantity, and refills, plus the checks you made: allergies, interactions, pregnancy or lactation, kidney function, and weight for children.
The structure is the same. This version spells out what NP programs and preceptors expect, such as a justified differential and prescribing checks, and works for any clinician.
Yes. Copy it, or download it as a Word or text file. No account needed.
The four-part note for most visits, with acute, musculoskeletal, and telehealth examples.
Examples of NP SOAP notes from chronic care, preventive, and virtual visits.
A step-by-step guide, with a checklist and the most common mistakes.
The history of present illness, with worked examples and a quality checklist.
The codes used most often in nurse practitioners.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.