Soap Note Nursing example

Nurses and other healthcare providers use the SOAP note as a documentation method to writing out notes in the patient’s chart. Soap Note nursing example are included in this post. SOAP stands for subjective, objective, assessment, and plan. SOAP Note nursing is the most common method of documentation used by providers to input notes into patients’ medical records. They allow providers to record and share information in a universal, systematic, and easy-to-read format.

Here are six soap note nursing example for nursing students

Soap note ABDOMINAL ASSESSMENT (Soap Note nursing example)


  • CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
  • HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
  • PMH: HTN, Diabetes, hx of GI bleed 4 years ago
  • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
  • Allergies: NKDA
  • FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
  • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)


  • VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
  • Diagnostics: None


  • Left lower quadrant pain
  • Gastroenteritis

SOAP Note Otitis externa

 Patient Information: JD, 11 years, Caucasian


CC (chief complaint) “my ear has been hurting for the past two days”

HPI: 11-year-old WM complaining of a mild earache for the past 2 days. The patient complains that it is harder for him to hear and the pain gets worse when the patient “falls asleep”. The pain is rated a four out of 10 in the pain scale. The location of the pain is on the right ear, and is a bother all the time. Lying on the right side and falling asleep exacerbate the pain. The patient uses Ibuprofen which helps relieve the pain

Current Medications: OTC Ibuprofen 200mg, one tablet in every 8 hours.

Allergies: None

PMHx: Immunizations up to date, Received tetanus and influenza shot 4 months ago, no surgeries, no previous hospitalizations, uneventful birth

Soc Hx: Lives with both parents, two siblings and grandmother. Grandmother takes care of the children as parents work. The patient enjoys swimming and outdoor activities. No exposure to second hand smoke

Fam Hx: Grandfather had type II diabetes and died at 78. No history of premature CVD.


GENERAL:  no weight loss or gain, has fever, experiences chills, grandmother reports feeling warm on touch

HEENT:  Slight hearing loss, mild ear pain on the right ear, slight hearing loss, No sneezing, congestion, runny nose or sore throat. Eyes:  No visual loss, blurred vision

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No Burning on urination.

NEUROLOGICAL:  headache, No dizziness, syncope, paralysis, ataxia

MUSCULOSKELETAL:  No back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  Prominent tan, denies sweating

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.


Physical exam (Soap Note nursing example)

VS: Temp-97.6, BP-100/67, HR-73, RR-22, O2 sat-100%, Height-4’13.5” (91stpercentile), Weight-78lbs (59thpercentile), BMI-16.7 (24thpercentile);

General Appearance: healthy-appearing, well-nourished, and well-developed

Cardiovascular– S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs Carotid Arteries: normal pulses bilaterally, no bruits present.

Respiratory- Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi

Gastrointestinal— No rigidity or guarding, no masses present,

Pulmonary—No difficulty in breathing or dyspnea

Diagnostic Tests (Soap Note nursing example)

  • Demonstration of osseous erosion on CT scanning


Differential Diagnoses

  • Otitis externa (Confirmed)
    • Associated with recent water exposure. The skin of the outer ear becomes erythematous, swollen, tender, and warm, leading to debris and discharge accumulation. Pain is worse when an otoscope is inserted because sensitivity is on the outer ear. Narrow external auditory canal with purulent discharge (Wiegand et al., 2019). PT meets this diagnosis criteria.
  • Otitis media with perforation (Refuted)
    • Clear discharge or bloody followed by relief of pain, with an inflamed tympanic membrane with perforation in the middle ear. Associated with ear pain, fever, difficulty hearing, irritability, and lethargy can also accompany this diagnosis. Inflammation in external part of the ear canal thus refuting this diagnosis (Pontefract et al., 2019).
  • Eustachian catarrh (Refuted)
    • Occurs in the middle ear, and results after an upper respiratory infection (Vasudevan & David, 2016). Patient has a no recent upper respiratory tract infection. Refuted
  • Ramsay Hunt syndrome (Refuted)
    • Complication of shingles. May present with symptoms of otitis externa, yet has evidence of vesicular eruptions within 2 days of first onset of pain. Pt has no history of shingles, Refuted (Musso & Crews, 2016).
  • Contact dermatitis (Refuted)
    • Allergic reaction to materials (e.g., metals, soaps, plastics) in contact with the skin/epithelium; itching is predominant (Schaefer, & Baugh, 2012). Pt has no piercing or known allergic reactions, refute
Soap Note nursing example
Soap Note nursing example

Focused SOAP Note for a patient with chest pain (Soap Note nursing example)

CC: “Chest pain” 

HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.

PMH: Positive history of GERD and hypertension is controlled

FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.

SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years 

General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema 
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis  


VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious (Soap Note nursing example)

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)


Differential Diagnosis: (Soap Note nursing example)

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Soap Note nursing example
Soap Note nursing example
Soap Note nursing example

Comprehensive SOAP Note COPD (Soap Note nursing example)

Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

Patient Initials: _______                 Age: _______                                   Gender: _______


Chief Complaint (CC): Coughing up phlegm and fever

History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.


  1. Lisinopril 10mg daily
  2. Combivent 2 puffs every 6 hours as needed
  3. Serovent daily
  4. Salmeterol daily
  5. Over the counter Ibuprofen 200mg -2 PO as needed
  6. Over the counter Benefiber
  7. Flonase 1 spray each night as needed for allergic rhinitis symptoms


Sulfa drugs – rash

Past Medical History (PMH):

1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.

2.) Hypertension – well controlled

3.) Gastroesophageal reflux (GERD) – quiet on no medication

4.) Osteopenia

5.) Allergic rhinitis

Past Surgical History (PSH):

  1. Cholecystectomy 1994
  2. Total abdominal hysterectomy (TAH) 1998

Sexual/Reproductive History:



Non-menstrating – TAH 1998

Personal/Social History:

She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.

Immunization History:

Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.  

Significant Family History:

Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.


She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.

She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.

Review of Systems:

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

HEENT: no changes in vision or hearing; she does wear glasses and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.

Neck: no pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said.

Breasts: No reports of breast changes. No history of lesions, masses or rashes. No history of abnormal mammograms.

Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.

CV: no chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

GI: No nausea or vomiting, reflux controlled, No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.

GU: no change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STD’s or HPV. She has not been sexually active since the death of her husband.

MS: she has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.

Psych: no history of anxiety or depression. No sleep disturbance, delusions or mental health history. She denied suicidal/homicidal history.

Neuro: no syncopal episodes or dizziness, no paresthesia, head aches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: no rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

Endocrine: no endocrine symptoms or hormone therapies.

Allergic/Immunologic: this has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago.


Physical Exam:

Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or tmegally

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes


Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%




CXR – cardiomegaly with air trapping and increased AP diameter


Normal sinus rhythm

Differential Diagnosis (DDx):

  1. Acute Bronchitis
  2. Pulmonary Embolis
  3. Lung Cancer

Diagnoses/Client Problems:

1.) COPD

2.) HTN, controlled

3.) Tobacco abuse – 40 pack year history

4.) Allergy to sulfa drugs – rash

5.) GERD – quiet on no current medication

Soap Note nursing example
Soap Note nursing example

SOAP Note Hyperlipidemia (Soap Note nursing example)

 Patient Information: X, 62 years old, Gender; Female, Caucasian


CC (chief complaint) the patient presents for her annual visit to the physician.

 HPI: Reports hypertension diagnosed at the age of 27 years, elevated total cholesterol level for the last ten years.

Current Medications: Lisinopril 5mg daily to control HTN

Allergies: None

PMHx: Lisinopril 5 mg daily
Soc Hx: Lives alone and is a divorcee. Works full time as graduate nursing program professor. Denies smoking history, admits she is an occasional drinker taking 2-3 ounces of wine when dining outside not more than 6 times a year.

Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 – 60 minutes of yoga, 45 – 60 minutes of step aerobics]; low glycemic Pescatarian; has not engaged with recommended colonoscopy, does not have screening mammograms, does not get a flu shot and has not had any other recommended adult immunizations

Fam HxN; /A.


GENERAL:  no weight loss or gain, has fever, experiences chills, grandmother reports feeling warm on touch

Physical Exam

Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9 temporal, R 16, SpO2 99%

HEENT:  Eyes no arcus senilis

SKIN:  Pink, Warm ad dry to touch.

CARDIOVASCULAR:  heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity edema; capillary refill < 3 seconds bilateral

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No Burning on urination.

NEUROLOGICAL:  headache, No dizziness, syncope, paralysis, ataxia

MUSCULOSKELETAL:  No lower extremity edema.







Physical exam

VS: Temp-97.6, BP-100/67, HR-73, RR-22, O2 sat-100%, Height-4’13.5” (91stpercentile), Weight-78lbs (59thpercentile), BMI-16.7 (24thpercentile);

General Appearance: healthy-appearing, well-nourished, and well-developed

Cardiovascular– S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs Carotid Arteries: normal pulses bilaterally, no bruits present.

Respiratory- N/A



Diagnostic Tests

  1. While the client’s cardiovascular readings all fall within the normal range as do the constitutional of BMI(21.8), BP(112/60) , P (68) T(97.9) R(16) SpO2 99% , her lipid panel results indicate that with a total cholesterol of 302, she has hyperlipidemia or hypercholesterolemia and should therefore be addressed. This is because a reading of total cholesterol level of 302 more than doubles her risk of having a heart attack.

Differential Diagnoses

Hyperlipidemia (Confirmed) According to Hill & Bordoni (2020) a lipid profile indicating total cholerestrol levels of 302 indicates hyperlipidemia.

Secondary disease processes (refuted) As with primary disorders, secondary disease processes  should be part of differential diagnosis for a patient with hyperlipidemia since liver disease, hypothyroidism, nephrotic syndrome , obesity and diabetes amongst other can lead to hyperlipidemia.(Hill & Borbodoni, 2020). However, the patient medical history shows there is no underlying disease that can be attributed as there are no such presenting symptoms. As such these were considered to highly unlikely.

Plan: To manage and treat the hyperlipidemia, the patient is advised to make dietary changes by increasing the salt intake, abstain from alcohol and take a lot of water to remain hydrated through the day. Medications like fludrocortisone to increase blood volume and midodrine to increase blood pressure may also have to be prescribed. According to Rhee et al (2019) therapeutic lifestyle modifications are also required to reinforce medication interventions. At the same time the patient is advised to increase her salt intake since the diastolic reading of reading can slip to below sixty which would indicate hypotension or low blood pressure. However, it is important to note that low blood pressure if not resulting from shock is not a major health issue but should be regulated all the same.


Managing low blood pressure; Since the patient  blood pressure is lower than normal , the patient is advised to take a lot of water to stay hydrated abstain from alcohol and increase the salt intake levels as sodium is known to raise blood pressure. If then hypotension becomes severe the physician may have to administer intravenous fluids. Other measures the patient is advised to take are to wear compression stockings. However, the physician should first establish what caused the hypotension as the patient’s age, and type of hypotension will dictate the best nonpharmacological approach. Likewise to lower her high cholesterol levels the patient is advised to make dietary changes where she should avoid red meat, and take cholesterol free measures

Patient Education

The physician with engage the patient in patient education and mainly focus on the non- pharmacological interventions for both hypotension where the blood pressure levels need to be raised even as the high cholesterol levels are brought done . In the event that medication will have to be used the patient will also be taught on the side effects of medication for hypotension as Flurodrocortisone can make some infections worse (Veazie et al., 2017). The patient education should emphasize that adhering to the non-pharmacological intervention is the best management options for the two conditions the patient is having.

Consultation and Collaboration

The patient will be specialist physicians majoring in diet and nutrition while a cardiovascular expert is also recommended in the healthcare team to manage to closely monitor the patients’ cholesterol levels. An interprofessional care team will benefit the patient as the two comorbidities will be managed to avoid progressing into worse levels giving rise to complications some which may increase the risk of heart disease which is usually a leading cause of premature death.

Soap Note nursing example
Soap Note nursing example

SOAP Note Hypertension Stage 3 or hypertensive crisis (Soap Note nursing example)

Patient Information: X, 57 years, Gender, Male, Race; Mixed (Black & Asian)


CC (chief complaint) ‘Comes for screening to participate in a study evaluating the effectiveness of a home cervical traction device on neck pain and intervertebral disc space’.

HPI: BP of 217/109.

Current Medications: N/A

Allergies: None

PMHx: Has a history of neck pain and was diagnosed with spinal stenosis at the C5-C6 level. Has known his BP to be in the range of 217/109 for the last 10 years.
Soc Hx: He is a healthcare professional at the provider level

Fam Hx:N/A.

















Physical exam

VS:  BP-207/109

General Appearance: healthy-appearing, well-nourished, and well-developed


Respiratory- N/A



Diagnostic Tests-N/A


Differential Diagnoses

  • Hypertension Stage 3 or hypertensive crisis (Confirmed) With a BP of This in and of itself indicates a hypertensive crisis (Pierin et al, 2019). It calls for immediate attention by a physician and therefore the patient has to be admitted. A diastolic value of 107 mmHg is better than the systolic value meaning the physician could classify it has hypertension Stage 2 but since the readings are different (one better and one worse the classification is correct to the one considered worse.
  • Hypertensive emergency (Refuted) unlike hypertensive urgency which has no associated target organ damage, the patient does not exhibit neurologic, aortic, cardiac, renal, and hematologic damage.
  • Secondary hypertension due to another underlying medical condition or drug abuse(Refuted) the patient does not report to have any chronic condition other that spinal stenosis that was diagnosed 6 six years ago. It is hypertension that causes chronic neck pain like the one of spondylosis. Neither does the patient report of having any drug or substance issues.

Therefore the patient cannot take part in the study as his assessment points towards Chronic, unregulated hypertension is diagnosed: specifically hypertension urgency.

Plan (P): Hypertension urgency. Promptly admit the patient for urgent hospital treatment and [pharmacologically manage the hypertension crisis. The physician further determines the type of hypertension crisis and determine that it is hypertensive urgency since there is no end organ damage (Alley & Schick, 2019). Most importantly, one should remember that if a hypertension crisis is not sufficiently treated aggressively, it can progress to hypertensive urgency where there is risk of death,


A more specific and comprehensive cardiac assessment will ensue that comprises of a physical exam, taking the blood pressure of each arm , listening to heart and lung sounds, renal arteries , neurological exam and a funduscopic assessment (Somand, 2020). These are followed by a comprehensive laboratory checkup and should the patient be found to have unbalanced pulses in the palms imaging studies will be required. The patient will also require oral and intravenous medications like diuretics and antihypertensive (for example hydralaxzine, nitrates and alpha beta blockers amongst others) to lower and maintain the patients’ blood pressure

Patient Education

Research studies had demonstrated the efficacy of patient education in helping the hypertensive patient to contain and maintain their blood pressure at comparatively lower levels. The patient needs to educate on medications used to treat and manage HTN and the need to adhere to the dosage without skipping the prescribed medication. The patient is also made aware of how to self-monitor their BP and self- care at home. Non pharmacological interventions like regular exercises, taking a HTN friendly diet and cessation of smoking are some of the lifestyle modification the patient has to comply with for a healthy and quality life. Sticking to the recommended diet and regular exercise will also have the benefit of checking unnecessary weight gain (Somand, 2020).

Consultation /Collaboration (Soap Note nursing example)

Once, the clinician is done with the patient, a referral can be made so that the patient can have a complete assessment conducted a consultant physician/ specialist like a cardiologist for close monitoring of the BP and medication efficacy as well as the levels of serum creatinine and potassium at least  twice a year.

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