Completed SOAP Note Example
See a realistic example of a well-written SOAP note, and understand why each piece of information sits where it does.
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Educational example showing how S, O, A, and P connect in a complete note
Patient reports:
“I’ve had a bad headache and feel nauseated.” Headache began last night and has progressively worsened this morning. Rates pain 7/10, throbbing. Bright light increases the pain; resting in a quiet, dark room provides some relief. Reports a history of migraines and states the current symptoms feel similar to previous episodes.
- Chief complaint
- History of present illness
- Associated symptoms
- Pain (with rating)
- Pertinent negatives
Nurse observes / measures:
- Temp 98.6°F (37°C); HR 88 bpm; RR 18/min; BP 124/78 mmHg; SpO₂ 98% on room air
- Appears uncomfortable and shields eyes from bright light
- Alert and oriented ×4; speech clear
- Pupils equal, round, and reactive to light
- No facial asymmetry or focal neurological deficit observed
- No vomiting observed; skin warm and dry; tolerating small sips of water
- Vital signs
- Physical assessment
- Diagnostic / lab results
- Observable findings
Nursing assessment:
Acute pain consistent with reported migraine symptoms, evidenced by throbbing headache rated 7/10, photophobia, nausea, and history of similar migraine episodes. Patient is hemodynamically stable with no observed acute neurological deficits. Nausea is present without vomiting; oral fluid intake is tolerated.
- Nursing diagnosis / clinical impression
- Evidence from S & O
- Patient status
Plan / interventions:
- Provide a quiet, dimly lit environment and encourage rest
- Administer prescribed analgesic or anti-migraine medication as ordered
- Encourage oral fluids as tolerated
- Monitor pain intensity, nausea, vital signs, and neurological status
- Reassess pain and response to interventions within 30–60 minutes
- Teach the patient to report worsening headache, vomiting, visual changes, weakness, or confusion
- Notify the provider if symptoms worsen or pain is not adequately relieved
- Nursing interventions
- Medications (as ordered)
- Patient education
- Monitoring
- Follow-up / evaluation
Why This SOAP Note Works
A strong SOAP note does more than place information under four headings. Each section has a distinct purpose, and the information should flow logically from what the patient reports to what you observe, what the findings indicate, and what happens next.
The symptoms, pain description, history, and concerns are reported by the patient.
Vital signs and assessment findings are observable or measurable.
The assessment synthesizes S + O instead of simply repeating them.
The plan responds directly to the identified problem and includes reassessment, education, and escalation.
Every line answers the one before it.
Subjective sets up Objective, Objective supports Assessment, and Assessment drives the Plan. Read the example in that order and the structure explains itself.
- Patient-reported information stays in Subjective.
- Objective contains only measurable findings.
- Assessment is supported by evidence.
- Plan directly responds to the identified problem.
- Documentation is concise, organized, and complete.
Your assessment should be supported by the information documented before it, and your plan should address the problem identified in the assessment.