Despina Petrushevska 
OT SOAP note sample: Free template and worked examples
Download your free OT SOAP note sample A four-page form with an identifying head...
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Last Updated: Nov 5, 2026
Practice Management Tips
SOAP note for nursing: structure, example and free template
Free PDF 1 page, print-ready Clinician-reviewed
A SOAP note for nursing is a structured clinical record that organizes each patient encounter into four parts: subjective, objective, assessment, and plan. Subjective holds what the patient reports, and objective holds what you measure. Assessment states the nursing diagnosis, and plan sets the next steps and a review date. Keeping facts and interpretation in separate sections lets the next shift trust the record. This guide walks through each section, a worked blood pressure example, and the charting mistakes to avoid, with a free template to download. In Pabau, the practice management platform we build, each note sits on the patient record beside the rest of the patient history.
Template details
- Template type
- Template
- Format
- Printable PDF, 1 page
- Sections
- 1 section
- Fields to complete
- 8 fields
- Best for
- Practice Management Tips
Free download
SOAP note for mental health
A ready-to-use SOAP note template built on the four-section subjective, objective, assessment, and plan layout. It was written for mental health encounters, so nurses should adapt the wording to their own setting before use.
What’s inside
- Patient Information
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Key takeaways
A SOAP note for nursing splits each encounter into four ordered sections.
Subjective holds patient reports, while objective holds measured findings.
Assessment states the nursing diagnosis, and plan lists interventions and follow-up.
Every plan needs a review date, so the next shift knows when to reassess.
Pabau stores each SOAP note on the patient record, so handoffs and audits read from one place.
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What a SOAP note for nursing is and why it matters
A SOAP note for nursing separates facts from interpretation, and that separation is why the format has lasted. Lawrence Weed developed the SOAP layout in the 1960s as part of the problem-oriented medical record, and clinicians have used it ever since.
Nurses rely on the format for three reasons:
- Handoffs: The next shift can see what was observed and what was planned.
- Review: Physicians, auditors, and insurers can follow the clinical reasoning.
- Accountability: Each section shows what was documented and when.
Joint Commission accreditation standards expect clinical records to be complete and timely. A consistent structure makes that easier to meet every shift. The wider charting rules nurses work under are set out in our guide to nursing documentation.
How to fill in each section
Work through the note in order, starting with the patient’s own account and ending with the plan. Each section should stand on its own, so a reader can see where every fact came from.
Subjective: what the patient reports
Subjective data is information only the patient or a family member can give you. Record the chief complaint in the patient’s own words, then add onset, severity, and relevant history.
- Chief complaint, quoted where the wording matters
- Onset, duration, and what makes symptoms better or worse
- Pain score on a 0 to 10 scale, if one applies
- Relevant medications, allergies, and history
Objective: what you measure and observe
Objective data is what you can measure, see, or test. Keep it factual and leave your interpretation for the assessment.
Typical entries include blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation (SpO2), along with physical exam findings. Record the time and method for each reading so the next clinician can compare results.
Assessment: your nursing diagnosis
The assessment states your nursing diagnosis and the reasoning that supports it. Many teams use NANDA International diagnostic labels because they give every reader the same wording.
Keep it specific. A vague entry like anxiety tells the next reader little, while a named diagnosis with the evidence behind it gives them something to act on.
Plan: interventions and follow-up
The plan lists what you did, what you taught, who you referred, and when you will reassess. A plan without a review date is hard to act on at the next visit.
- Interventions completed during the visit
- Patient education and the result of teach-back
- Referrals and communication with the provider
- Evaluation date and the outcome you expect
A worked example from a blood pressure follow-up
This example shows a SOAP note for nursing written after a primary care follow-up. It is illustrative, so adapt it to your facility’s policies and your state’s scope of practice.
Subjective: The patient, a 58-year-old man, reports morning headaches for two weeks. He missed two doses of his blood pressure medication last week because of his work schedule.
Objective: BP 152/94 mmHg on recheck after five minutes seated. Heart rate 78, respiratory rate 16, SpO2 98% on room air, and no edema. His home log shows readings above 140/90 on four of the last seven days.
Assessment: Blood pressure is above target. Nursing diagnosis: Ineffective health management related to missed doses. He understands his medication but finds the schedule hard to keep on workdays. His high home readings line up with the missed doses.
Plan: Reviewed the home BP log with the patient and used teach-back to confirm his dosing times. He agreed to take the morning dose with breakfast and set a daily phone reminder. Provider notified of today’s reading. Recheck BP in two weeks, or sooner if headaches worsen or a home reading reaches 180/120 mmHg.
Each section answers one question. The subjective records what he said, and the objective records what was measured. The assessment links the two, and the plan says what happens before the next visit.
The diagram files the same visit section by section, next to the entry each section most often picks up by mistake.
To see the format applied outside nursing, these SOAP notes examples cover several other specialties.
What’s in the free template
The free template gives you a one-page form built on the same four sections. It is a blank structure, so you write every entry in your own words.
- Patient information: First name, last name, date of birth, and the date of the encounter.
- Subjective, objective, assessment, and plan: One open writing space for each section, in that order.
- Signature: A line to sign the note once it is complete.
The form is titled for mental health encounters, but the four sections are the same for nursing. Check the wording against your facility’s documentation policy before you use it.
SOAP notes vs other nursing documentation formats
SOAP is not the only structure nurses use. Your facility may ask for a different format depending on the setting and the purpose of the note.
Use the format your facility’s policy names. If you hand off a patient verbally, an SBAR nursing handoff often sits alongside the written SOAP note.
When the note covers a single event, a DAR notes template keeps the data, action, and response together. Units that chart against a care plan often use a PIE nursing chart instead.
Common mistakes in nursing SOAP notes
Most errors in nursing SOAP notes come from putting a fact in the wrong section or leaving a section incomplete. These six cause the most trouble at handoff or audit.
- Opinion in the objective section: “Patient seems anxious” is an interpretation. Record what you saw, such as pacing or a raised heart rate.
- A vague assessment: A single word gives the next nurse nothing to act on. Name the diagnosis and the evidence behind it.
- A plan with no review date: Every plan needs a time to reassess, or the next shift has to guess.
- Copying forward old entries: Copied text can carry outdated vitals or resolved problems into a new note. Write each entry for this encounter.
- Unclear abbreviations: Use only the abbreviations your facility approves, and avoid any on its do-not-use list.
- Late entries without a label: If you document after the fact, mark the entry as late and record the actual time of care.
How Pabau keeps SOAP notes on the patient record
Paper SOAP notes get filed in one place while the rest of the patient history sits somewhere else. The next nurse then searches two systems before a handoff, and an auditor has to match them by hand.
Pabau keeps each note in the patient record, next to appointments, forms, and treatment history. Pabau’s digital forms can turn a SOAP layout into a structured form that saves straight to that record.
Pabau Scribe, our AI scribe, can also draft notes from the consultation for the clinician to review. The nurse still checks and signs every entry, but the typing load drops.
See structured notes in a full patient record
Book a demo to see how SOAP notes sit alongside appointments, forms, and patient history in Pabau.
Conclusion
A SOAP note for nursing works when each section does one job. Keep facts and interpretation apart, and the next nurse can trust what you wrote.
Start with the template and use the same order every shift. Give every plan a review date, because that is the line the next reader acts on.
Book a demo to see how Pabau keeps every SOAP note on the patient record your team already uses.
Continue your research
Need more worked examples? SOAP notes examples shows the format across several specialties.
Handing off at the end of a shift? SBAR nursing handoff template structures the verbal report that goes with your notes.
Prefer a free-text format? Nursing narrative note template covers when a narrative entry fits better than SOAP.
Discharging a patient? Nursing discharge note lists what the final nursing record must include.
Tracking a patient over several visits? SOAP progress notes template gives you the same four sections for follow-up entries.
Frequently asked questions
What is a SOAP note for nursing?
A SOAP note for nursing is a structured record of a patient encounter in four sections: subjective, objective, assessment, and plan. It separates what the patient reports from what the nurse measures and concludes.
What is the difference between subjective and objective data?
Subjective data comes from the patient or family, such as symptoms and pain scores. Objective data is what you measure or observe, such as vital signs and exam findings.
What goes in the assessment section of a nursing SOAP note?
The assessment states the nursing diagnosis and the reasoning behind it. Many teams use NANDA International labels so every reader sees the same wording.
How is a SOAP note different from SOAPIE?
SOAPIE adds two sections to SOAP: intervention and evaluation. It records what was done and how the patient responded in the same note.
Can I use the free template for nursing notes?
Yes. The form uses the standard four SOAP sections with patient details and a signature line. It is titled for mental health, so adapt the wording to your facility’s policy.
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