Free SOAP Note Template
This blank SOAP note template helps you organize patient information into Subjective, Objective, Assessment, and Plan sections.
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Subjective • Objective • Assessment • Plan
- Chief complaint / reason for visit
- History of present illness / current symptoms
- Symptoms and symptom characteristics
- Onset / duration
- Pain / aggravating or relieving factors
- Relevant history and pertinent negatives
- Patient concerns
- Vital signs
- Physical assessment / observable findings
- Observations
- Relevant diagnostic / laboratory findings
- Measurements
- Other objective data
- Nursing diagnosis / clinical impression
- Problem status
- Supporting findings from S and O
- Patient response to treatment
- Risk factors
- Notes
- Interventions / monitoring / reassessment
- Treatments or medications as ordered
- Patient education
- Monitoring and reassessment
- Referrals / tests
- Follow-up
Name
Date of birth
Age
Date
Time
Provider / instructor
| Temp | °F / °C | |
|---|---|---|
| HR | bpm | |
| RR | /min | |
| BP | mmHg | |
| SpO₂ | % | |
| Pain | /10 |
How to Use This SOAP Note Template
Each section of a SOAP note has a different purpose. Keep patient-reported information separate from observable findings, then use those findings to support your assessment and plan.
Record the patient’s symptoms, concerns, pain, relevant history, and other information reported by the patient.
Record measurable and observable findings such as vital signs, physical assessment findings, and relevant test results.
Connect the relevant subjective and objective findings to the nursing problem, clinical impression, or assessment required by your assignment.
Document appropriate interventions, monitoring, patient education, treatments as ordered, and follow-up.
Good notes are how care gets handed over.
A clear SOAP note tells the next nurse what the patient reported, what you observed, what it means and what happens next — without them having to ask.
Before You Finish Your SOAP Note
- Keep patient-reported information in Subjective.
- Keep observable and measurable information in Objective.
- Make sure your Assessment is supported by S and O.
- Make sure your Plan responds to the problem identified in the Assessment.
- Be specific and concise rather than adding information simply to make the note longer.