3 Perfect Nurse Practitioner SOAP Note Examples + How to Write
Written By:
Darby Faubion
Darby Faubion RN, BSN, MBA
Darby Faubion is a nurse and allied health instructor with over 20 years of clinical experience. Darby lives in Louisiana and loves exploring the state’s rich culture and history. Darby has a passion for caring for veterans and a special interest in those affected by post-traumatic stress disorder. In her quest to make a difference for veterans, she founded a non-profit called “Operation Battle Buddy.” Read Full Bio »» RN, BSN, MBA
As a nurse practitioner, you understand the importance of timely, accurate documentation. There are many types of documentation and formats you can follow when documenting, and one of the most common is the SOAP note. If you are serious about creating good documentation, you may wonder, “Who can tell me exactly how to write a nurse practitioner soap note?”
NP soap notes should have four essential components and follow the SOAP format. In this article, I will share 3 perfect nurse practitioner SOAP note examples + how to write them. Although nurses have different ways of documenting, if you follow the SOAP format and include the required components, you should be able to create an NP SOAP note that is relevant to all members of the healthcare team.
What is a Nurse Practitioner Soap Note?
Nurse practitioner SOAP notes are a structured form of nursing documentation used to record the nurse practitioner’s findings about a patient.
These notes are a type of patient progress note that follow a structured format and are used to document essential information from patient encounters.
What is the Purpose of Writing a Nurse Practitioner Soap Note?
The purpose of a nurse practitioner SOAP note is to guide nurse practitioners in their use of clinical reasoning when assessing, diagnosing, and treating patients. NP SOAP notes record information about the patient, their past and present medical history, their diagnosis, and treatment plans, and facilitate communication between members of the healthcare delivery team.
What Components Should Be Included in NP Soap Notes?
Nurse practitioner SOAP notes are comprised of four components:
subjective data, objective data, assessment, and planning. Each component of the note is essential for creating an accurate description of the patient’s status, concerns, needs, diagnosis, and treatment plan. The following are the four main components of NP SOAP notes.
COMPONENT #1: Subjective Data
The first component of NP soap notes is Subjective Data (S). Subjective data includes any information obtained directly from the patient or their loved one/caregiver. Examples of subjective data include their medical, family, and social history and any symptoms the patient is experiencing, including pain, nausea, or vomiting. Information such as current medications the patient is taking, any allergies, and a review of systems are subjective data. Anything the patient, or "subject," feels or expresses to you is considered subjective data.
COMPONENT #2: Objective Data
The second component of an NP SOAP note is Objective Data (O). Objective data is any information or data that can be observed or measured. For example, vital signs, physical examination findings, lab values, and other diagnostic test results are considered observable or measurable and, therefore, are objective data.
COMPONENT #3: Assessment
The Assessment part of an NP SOAP note is the component of the note is a summary of the combined subjective and objective data used to make differential diagnoses and a final diagnosis. Without a thorough assessment, it is impossible to form an accurate diagnosis, which means you cannot create an appropriate treatment plan. In this section of the SOAP note, the nurse practitioner includes reasons for coming to a differential diagnosis or final diagnosis.
COMPONENT #4: Plan of Care
The final component of nurse practitioner SOAP notes is the
Plan of Care. After using subjective and objective information to form a diagnosis, the nurse practitioner must create a care plan to address the diagnosis. This component of the NP SOAP note lists diagnoses, interventions, and expected outcomes. It may include medication orders, orders for diagnostic tests, or referrals to healthcare specialists or support services. The plan of care also includes patient education and their response to education and notes about any follow-up appointments.
How to Write a Nurse Practitioner Soap Note?
(The following is a step-by-step process to write a perfect NP SOAP note.)
STEP #1: Gather Subjective Data by Interviewing the Patient
The first step in creating a nurse practitioner SOAP note is to interview your patient. As you talk to your patient, your goal is to gather information from the patient’s perspective. Any thought or feeling the patient conveys to you is essential to creating an accurate, usable SOAP note. Ask open-ended questions. For example, instead of saying, “Are you in pain?” ask, “Can you describe your pain?” Open-ended questions signal to the patient that their thoughts and feelings are important and encourage communication. Your interview should include a Review of Symptoms, which is what the patient tells you about each body system, prompted by questions from you.
STEP #2: Review the Patient’s Chart and Any Test Results for Objective Data
An essential step in gathering objective data is to review the patient’s chart. By reviewing the patient’s chart and any laboratory or diagnostic test results, you can find vital information to follow up on with your assessment and upon which to base your diagnosis.
STEP #3: Perform an Assessment to Obtain Additional Objective Information
Performing a thorough assessment is essential in preparing NP SOAP notes. Your assessment should include measuring vital signs and an objective
review of all body systems to compare to the patient's responses to the interview. You should list your patient's complaints in order of priority.
STEP #4: Determine Differential Diagnoses
After reviewing subjective and objective data and performing your assessment, you will create a differential diagnosis from which you will make your final diagnosis. A differential diagnosis is a list of possible health conditions that share similar symptoms. (IMPORTANT NOTE: A differential diagnosis is only needed when there is a new complaint. If your patient is being seen for a follow-up visit without new s/sx, you do not need a differential diagnosis for your NP SOAP note.)
STEP #5: Document Your Final Diagnosis
You will use the differential diagnosis to determine which tests need to be performed and to rule out conditions that do not lead to the final diagnosis. After eliminating the diagnoses that are not applicable, you will make a final diagnosis and document your findings.
If you are seeing the patient for a follow-up visit, your diagnosis will be the diagnosis given at the last visit or discharge unless new symptoms/complaints are present.
STEP #6: Create a Plan of Care and Record it in the SOAP Note
Once a diagnosis is made, the next step is to create a plan of care and document it. You will work with the patient, family members, and the interdisciplinary team to establish a mutually acceptable, evidence-based plan to address your patient’s immediate needs. Your Plan of Care should include any tests or medications ordered, specialist or support services referrals needed, and should also include the patient’s response to the suggested plan. For example,
“Plan of Care discussed with pt. Pt. agrees and verbalizes understanding of the importance of medication compliance and keeping follow-up appointments.”
What are the Perfect Examples of Nurse Practitioner Soap Notes?
(Below are 3 perfect NP SOAP note examples.)
EXAMPLE #1: Patient with Urinary Tract Infection (Family Nurse Practitioner SOAP Note) |
Date: 10/01/23
Pt. Name: Mary Parker
Chief Complaint: Burning, frequent, painful urination
Subjective:
Patient M.P. is a 21 y/o white female who presents to the clinic today with complaints of frequent, burning, painful urination. States she feels the need to void three or four times every hour. Reports cloudy urine with strong smell. Denies nausea, fever, vomiting, flank pain, hematuria, vulvar/vaginal irritation, or vaginal discharge.
Past Medical History:
No significant childhood medical history.
Adult medical history: frequent sinus infections.
Pt. has never been pregnant, reports no reproductive disorders or concerns, and states she has used birth control (Depo Provera) since becoming sexually active at age 18. States she used spermicidal pregnancy prevention before the last Depo Provera injection because she missed her scheduled appointment. Last GYN appt. 09/04/2023 with no significant findings.
Surgical History: None
Psychiatric History: None
Medications: Depo Provera q 12 weeks; Denies taking any other prescription medication, OTC medications, or supplements.
Allergies: No Known Allergies
Family Medical History:
Father- living, Hx/O HTN
Mother- deceased, Hx/O Breast CA with metastasis to bones
Has two siblings, one brother and one sister, with no significant medical history
Review of Systems:
General- No generalized fatigue or weakness; no changes in appetite or weight
Respiratory- Denies cough, SOB; no history of seasonal allergies or asthma
Cardiovascular- Denies orthopnea, edema, fatigue; denies hx/o HTN, high cholesterol, or heart murmur
Gastrointestinal- Reports mild suprapubic discomfort; denies abdominal pain, nausea, or vomiting
Genitourinary- Reports urinary urgency and dysuria x3 days.
OBJECTIVE:
General:
Appearance: M.P. is alert, oriented, and cooperative. Pt. is well-groomed. Pleasant affect.
Vital Signs: B/P 118/78, P 72, R 18, T 98.6
Height: 67 inches Weight: 181 lbs.
ASSESSMENT:
Respiratory: Lungs CTAB, respirations even, nonlabored
Cardiovascular: HR regular, no murmur, rubs, or gallops noted. No lifts, heaves, or thrills.
Gastrointestinal: Abdomen soft, non-tender to palpation, BS positive x4 quadrants
Genitourinary: Suprapubic tenderness noted on palpation
Labs:
1. Dipstick Urinalysis: Positive for leukocyte esterase and nitrites
2. Urine Culture: Pending
Differential Diagnosis: pyelonephritis, overactive bladder, vaginitis
Diagnosis: Urinary Tract Infection, site not specified
The diagnosis of UTI was made based on pt.’s chief complaint, history of present symptoms, dipstick U/A result, and physical examination findings. Clinical indicators of UTI include urinary frequency, urinary urgency, dysuria, and suprapubic tenderness. Pyelonephritis ruled out r/t absence of nausea, vomiting, flank pain, and fever. Overactive bladder ruled out r/t dipstick U/A results. Vaginitis was ruled out r/t absence of vaginal discharge, vaginal or vulvar irritation, and due to U/A dipstick result.
PLAN of CARE:
Plan: 1. Bactrim DS 1 po BIDx 3 days
2. Educated pt. on the importance of completing the full course of antibiotics.
3. Educated pt. on perineal hygiene, including wiping from front to back to prevent the spread of bacteria to the urinary tract.
4. Advised pt. drink at least eight glasses of water each day, reiterating that water discourages the growth of bacteria by flushing the urinary tract.
5. Educated pt. to avoid the use of spermicidal products as they decrease vaginal lactobacilli, which can increase the risk of UTIs.
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EXAMPLE #2: F/U for Psychiatric Patient following Inpatient Treatment (PMHNP SOAP Note) |
Date: 10/01/23
Pt. Name: James Masters
Chief Complaint: Follow-Up Visit r/t Inpatient Psychiatric Care
Subjective:
Patient J.M. is a 55 y/o male presenting for follow-up after inpatient psychiatric admission. Pt states he is feeling better now than he has in several months. States although he feels down at times, feelings of depression have improved. Also reports sleep has improved and that he is sleeping 7-8 hours of uninterrupted, restful sleep at night. Denies suicidal thoughts or ideations.
Past Medical History:
No significant childhood medical history.
Adult medical history: No significant medical history
Surgical History:
Appendectomy (1999)
Psychiatric History: Major Depressive Disorder w/o Psychosis, Generalized Anxiety Disorder
Medications: Mirtazapine 30 mg. 1 qhs, Fluoxetine 40 mg. 1 qd
Allergies: No Known Allergies
Family Medical History:
Father- deceased, Hx/O DM Type 1
Mother- living, Hx/O CHF, HTN
Pt. is an only child.
Review of Systems:
General- No generalized fatigue or weakness; reports slightly decreased appetite, but no changes in weight noted
Respiratory- Denies cough, SOB; no history of allergies or asthma
Cardiovascular- Denies edema, orthopnea, or fatigue; denies hx/o HTN, high cholesterol, or heart murmur
Gastrointestinal- Denies c/o abdominal pain or discomfort; last BM this am
Genitourinary- Denies c/o urinary frequency, urgency, or dysuria
OBJECTIVE:
General:
Appearance: J.M. is alert, oriented, and cooperative. Pt. is well-groomed and dressed seasonally appropriately. Pleasant affect noted.
Vital Signs: B/P 120/82, P 78, R 16, T 98.4
Height: 72 inches Weight: 210 lbs.
ASSESSMENT:
Respiratory: Lungs CTAB, respirations regular, even, and nonlabored
Cardiovascular: HR and rhythm are normal. The external chest is normal in appearance, with no thrills, lifts, or heaves.
Gastrointestinal: Abdomen soft, non-tender, with active BS x4 quads.
Genitourinary: No abnormal GU symptoms noted
Diagnosis: Major Depressive Disorder, recurrent w/o Psychosis; Generalized Anxiety Disorder
PLAN of CARE:
Plan:
1. Pt. Will continue Mirtazapine 30 mg. @ hs and Fluoxetine 40 mg. qd
2. Outpatient counseling once weekly
3. Return to clinic in one month for follow-up or earlier if depression or anxiety symptoms worsen.
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EXAMPLE #3: Premature Infant Follow-Up Visit (Neonatal NP SOAP Note) |
Date: 10/04/23
Pt. Name: Ashlynn Reeves
Chief Complaint: F/U visit Premature Birth; Low Birth Weight
Subjective:
Patient A.R. is a 4-week-old white female presenting to the pediatric clinic following NICU discharge. Pt. presents in mother's arm. The mother states pt. is nursing well, every two to three hours, and sleeping well. No changes in appetite noticed, has approximately 2 to 3 BMs each day, and 4 to 5 wet diapers daily.
Past Medical History:
Premature birth at 34 weeks gestation; delivered through spontaneous, uncomplicated vaginal delivery. Birth weight was 4 lbs. 2 oz. and length was 18.1 inches. Pt. stayed in NICU for two weeks, then discharged to home with home health services to monitor weight.
Mother denies prenatal complications or significant health history. This is her first child.
Medications: None
Allergies: No Known Allergies
Immunizations: Hepatitis B vaccine admn. 0n 9/7/23
Family Medical History:
Father- living, no significant history
Mother- living, no significant history
Pt. is the father’s third child and mother’s only child.
Review of Systems:
General- Mother reports no complaints, pt eating well, normal sleep patterns
Respiratory- Mother denies cough or other signs of respiratory distress
Cardiovascular- Mother denies any CV s/sx
Gastrointestinal- Mother reports pt has 2-3 yellowish-colored stools daily
Genitourinary- Mother reports 4-5 wet diapers daily
OBJECTIVE:
HEENT:HEAD: Anterior fontanelle flat, soft. Normocephalic, Sutures apposed. EYES: Conjunctivae pink, negative for discharge, PERRLA; NOSE: pink mucosa, no discharge; MOUTH/THROAT: pink mucosa, no lesions or presence of thrush, PHARYNX negative for erythema or exudates.
NECK: No lymphadenopathy noted, supple
CHEST: No visual abnormalities, clavicle intact
RESPIRATORY: Lungs CTAB, breath sounds equal, no rales, rhonchi, or wheezes noted
CARDIOVASCULAR: HR regular, normal S1/S2, Negative for murmur; femoral pulses present x2/equal
GASTROINTESTINAL: Abdomen soft, nontender, bowel sounds present x4; no masses; negative for sx of hepatosplenomegaly; umbilical stump present, black in color, no discharge noted.
GENITOURINARY: Normal female presentation; no labial adhesions
ANUS: Regular in appearance, no swelling or fissures noted
INTEGUMENTARY: Small areas of erythema present on upper extremities and chest; presence of diffuse lanugo on back
EXTREMITIES: Symmetric creases, normal ROM, negative for hip clicks; no hand or foot deformities; negative Ortolani/Barlow Maneuver
SPINE: No dimples or defects; normal curvature
NEUROLOGIC: Motor/sensory normal; cranial nerves intact, normal tone
Vital Signs: B/P 88/50, P 148, R 44, T 98.5 Weight: 6 lbs. 10 oz.
ASSESSMENT:
4-week-old female infant born at 34 weeks gestation. Birth weight has increased by 2 lbs. 8 oz. Pt brought by the mother, who voices no concerns today. Infant sleeping in mother's arms. No acute s/sx noted.
Diagnosis: Premature Infant, Low Birth Weight
PLAN of CARE:
Plan:1. Will follow up in clinic in two weeks for weight check and to address any new concerns
2. Discussed age-appropriate infant behaviors, feeding, newborn care, and safety measures and provided handouts.
3. Discussed limiting visits with others to avoid exposure to illness.
4. Advised mother to report any changes in feeding, weight loss, or other concerns
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My Final Thoughts
One of the most important responsibilities of nurses is documentation, and a SOAP note is one of the most common types of nursing notes used. As a nurse practitioner, you may have wondered, “Can someone tell me how to write a nurse practitioner soap note?” In this article, I shared 3 perfect nurse practitioner SOAP note examples + how to write them.
SOAP notes may be written a little differently from one nurse practitioner to the next. However, as long as the important components, Subjective and Objective Data, Assessment, and Planning, are covered, the note should be acceptable. The most important tip I can give you regarding writing NP SOAP notes, or any other documentation is to remember if you did not document, the law says you did not do it.
Frequently Asked Questions Answered by Our Expert
1. Who Can Write NP SOAP Notes?
Nurse practitioners and nurse practitioner students can write nurse practitioner SOAP notes.
2. When To Write NP SOAP Notes?
A nurse practitioner SOAP note should be written any time there is a new patient encounter or change in the patient’s status to promote continuity of care across the interdisciplinary team.
3. Ideally, How Long Should NP SOAP Notes Be?
Ideally, NP SOAP notes should be one to two pages long. Most sections have one or two paragraphs. However, the length may vary based on the patient’s status and the amount of information you need to record in the SOAP note.
4. What’s The Most Important Part Of NP SOAP Note?
Subjective and objective information help you form a diagnosis, which leads to your plan of care. Therefore, every component of a nurse practitioner SOAP note is essential.
5. Can I Use Abbreviations In NP SOAP Notes?
It is acceptable to use abbreviations when writing NP SOAP notes. Be sure to verify the list of approved abbreviations for your facility.
6. What Tense Do I Write NP SOAP Notes?
Nurse practitioner SOAP notes should be written in the present tense.
7. Are NP SOAP Notes Handwritten Or Printed?
Many facilities now use electronic health records for recording documentation. However, if you work in a facility that does not use EHRs, NP SOAP notes may be handwritten or printed as long as the note is legible.
8. How To Sign Off NP SOAP Notes?
To sign off on a nurse practitioner SOAP note, sign your name followed by your credentials. Some facilities may require you to add the date and time when signing off, but others expect the date and time to be recorded at the beginning of the note.
Darby Faubion, RN, BSN, MBA
Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX).