How Mastering SOAP Notes Can Boost Your Nursing Career with Examples
Proper charting is a vital form of communication among clinical professionals that adheres to medical and legal guidelines. All clinicians and students must be able to write SOAP notes effectively. Remember, if you don’t chart it, you didn’t do it! Documentation enables you to take full credit for your hard work.
But what if there’s more? You’ve spent years documenting patient care… now those same skills can help you grow as a clinician and explore new roles.
Click here for a free template of obstetric progress, admission, and discharge notes.
Why SOAP Notes Matter Beyond Bedside Nursing
Documentation in healthcare provides a concise and complete record that describes a full report of observations, data collection, and interventions. However, it’s not always that easy. Many healthcare professionals are concerned about the time and pressure that proper documentation adds to their workload.
By becoming better at writing SOAP notes, you can increase your efficiency, decrease your workload, communicate better with colleagues, and support “future you” in court.
This article will break down the basics of how to write a SOAP note with obstetric examples.
Breaking Down the SOAP Note (S.O.A.P.)
- S: Subjective Data
- O: Objective Data
- A: Assessment (Diagnosis)
- P: Plan
Subjective Data
Subjective data refers to the description that the patient provides. It cannot be measured.
Subjective data is what the patient tells you.
Here are examples of what comes after Subjective data:
- Demographics: age, sex
- Chief Complaint (CC): Why are they here? Use their words (“I am having contractions”; “I think my water broke”). Some places avoid using terminology like ‘complaint’ because it can negatively impact the patient.
- History of Present Illness (HPI): All medical information relevant to today’s presenting issue. Consider their current situation and any other relevant information.
- Obstetric History (ObHx): Provide their pregnancy history(Gravida/Para or GTPAL- Gravida Term Birth, Preterm Birth, Abortions, Living Children)
- Past Medical History (PMH): Any medical condition in their past, e.g., Hypertension, Diabetes, etc.
- Past Surgical History (PSH): Any surgical condition in their past, e.g., wisdom teeth extraction, foot surgery, etc.
- Family History (FamHx): Interview the patient about their mother, father, siblings, and grandparents on both sides. Include any important history, such as hypertension, cancer, stroke, cardiac disease, or diabetes. For gynecologic note-taking, please pay careful attention to reproductive health cancers and their candidacy for genetic screening (BRCA, COLARIS).
- Social History: Alcohol, tobacco use, recreational drug use, seatbelt safety, guns, domestic history, and mental health history.
Objective Data
Data that the health provider can directly observe. It CAN be measured
General appearance: Is the patient alert and oriented? Is the patient in mild, moderate, or severe distress? Does the patient appear healthy and well-nourished?
Vital signs: blood pressure, pulse, respiration, temperature, height, weight.
Physical exam findings:
- Head, Ears, Ears, Nose, Throat (HEENT): Is the head normocephalic? Are there any issues with the sinuses? What does the tympanic membrane look like in the ear? Is there any discharge from the ears, eyes, or nose? Describe it. What is the appearance of the mouth, nose, and throat mucous membranes? Are the nares patent? Is there exudate or swelling from the tonsils?
- Neck: Describe ROM, skin, and thyroid.
- Heart: Describe the rate and rhythm. Are there any murmurs or additional heart sounds? Capillary refill? Bruits?
- Lungs: Are there any crackles or wheezes? Are they clear to auscultation?
- Abdomen: Is it soft? Is it tender? Is it distended? Can you hear bowel sounds in all four quadrants? Describe the inguinal area.
- Musculoskeletal: Is the spine aligned? ROM of the spine? Is there erythema or tenderness? Tenderness? Muscular development? Gait?
- Back: Examine the spine. Gait? Posture? Spinal deformity? Are the spinal muscles symmetric? Muscle spasms? CVA tenderness?
- Extremities: Think of both upper and lower. Are there any deformities or joint abnormalities? Are the pulses intact? ROM? Are there any varicosities? Is there any cyanosis, clubbing, or edema? Describe reflexes.
- Neurologic: Are there any neurologic issues? HA? Visual disturbances like blurred vision, floaters, or light disturbances?
- Skin: Is it warm or cool to the touch? Moist or dry? Describe any rash or tenderness.
- Fetus: Is the patient pregnant? Bimanual exam results? Fetal heart tone range? Are they feeling fetal movement? What is the EDD or estimated gestational age?
Labs: Write down the results of any labs that are relevant and available today (Urinalysis, blood sugar, labs, and available from the prior visit).
Imaging: Include imaging results from the prior visit, such as the dating, nuchal translucency (NT), anatomy, or growth ultrasounds.
Assessment
Assessment means diagnosis.
Under assessment, include:
- Diagnosis
- Differential diagnosis
The diagnosis can be as simple as an intrauterine pregnancy and gestational age or specific to a disease process like preeclampsia or GDMA1 (or A1GDMA). If you are concerned about differential diagnoses, they should also be listed in this section.
Plan
What will you do to treat the diagnosis?
Use consistent abbreviations and templates to streamline your workflow and save time.
- Medications prescribed
- Diagnostics ordered: labs, ultrasound, radiology
- Therapeutic: diet, activity
- Patient education provided
- Referrals: specialties, therapies, other services
- Disposition: Discharge home, continue monitoring, transfer units.
SOAPIE
While the SOAP format is the most widely recognized structure, many hospitals and nursing educators utilize an expanded method called SOAPIE for more comprehensive documentation.
This expanded format explicitly captures the implementation and effectiveness of nursing care by adding two extra components to the end of the traditional SOAP note:
I is for Intervention
This section documents all specific actions you took to carry out the Plan. This aligns with the Implementation phase of the nursing process.
- What to include: Specific treatments, medications administered, patient education provided, or any action taken by the nurse or care team.
- Example: Administered 5mg of oral morphine as per plan. Repositioned the patient to high-Fowler’s position.
E is for Evaluation
This is arguably the most crucial addition. Here, you document the patient’s immediate response to your intervention and reassess their status. This step proves the effectiveness of your nursing care and guides the decision for the next steps.
- What to include: A re-assessment of the Subjective/Objective data. Did the intervention work? How did the patient change?
- Example: Patient reported pain level decreased from 7/10 to 3/10 thirty minutes after morphine administration. Denies feeling dizzy. Will continue to monitor.
By adding these two letters, the SOAPIE note provides a comprehensive record that links the initial assessment, the plan, the action, and the outcome, making it an incredibly robust and widely used format in clinical practice.
Using Your Documentation Skills to Build a Nontraditional Nursing Career
Strong documentation skills for nurses are a foundation not only for clinical excellence but also for expanding your career into nontraditional nursing roles. From legal consulting to healthcare writing, education, informatics, and policy work, the ability to accurately capture patient encounters and synthesize information is highly valued.
The ability to synthesize complex clinical data into a concise, actionable narrative is an extremely valuable skill that benefits many other professional roles. These are the skills needed for writing, consulting, and informatics.
Nurses with experience in thorough charting, SOAP notes, and evidence-based documentation can leverage these skills to transition into roles that influence healthcare beyond bedside care.
Free Template: Charting Example
Initial Prenatal Visit: New Obstetric Antepartum SOAP note example
Subjective (S)
Demographics: 19 yo G1P1000 @ 10w2d by irregular periods and unsure LMP
CC: Unintended pregnancy. Pt is accepting but overwhelmed. Unmarried, FOB involved. Presenting for obstetric care as a new patient for the first antepartum visit.
HPI Believes LMP to be around 1/24/2015 (“sometime between Valentine’s Day and New Year’s Eve, probably the last week of January”). Unsure intercourse timing. Positive HPT: 3/17/2015 because she wanted to see if she “should have a green beer.” Healthy, well-nourished female. C/o nausea, first thing in the morning for the last two weeks. Amenorrhea, increased frequency of urination, fatigue, and breast tenderness began about four weeks ago. Denies dizziness, HA, visual disturbances, and edema. C/o nausea and vomiting in early AM and after large meals. Denies vaginal discharge, odor, bleeding, and cramping. Eats fruits and hydrates appropriately. Pt is not currently exercising.
OB/GYN History: G1P0. No hx of STI.
Yearly Pap: No Pap was indicated at <21 yo per ACOG guidelines.
Past medical/surgical History:
- Allergies: NKDA
- No medical Hx
- Surgical Hx: wisdom teeth removed 2012
- Chewable PNV PO daily with 800 mcg of folic acid
- Flu immunization, October 2014, TDaP 2008
FH (Family History)
- Father died of colon cancer at age 54 (2009)
- Mother had cervical cancer (2010), is alive and stable
- Maternal Grandfather with Type II diabetes & neuropathy. Alive.
- Maternal Grandmother died in an MVA in 2017. No health issues.
- Unknown paternal grandparents.
SH (Social/Personal History) Single, attending college for nursing, works FT as a waitress, no drug use, 5-7 glasses of beer per week before pregnancy (1-2 at one time). Has not consumed alcohol since 3/1/2015. Never smoker. Christian, non-denominational. No domestic violence. Does not have a cat and no litter box. Personal – Denies hx of abuse, mental illness, depression, anxiety, or eating disorders.
Objective (O)
General appearance: The patient is alert, oriented X 4, and in no acute distress.
BP 118/68 P 68 Resp rate 18
Ht: 64” Wt: 115 lbs BMI: 19.7
HEENT: Head is normocephalic. The sinuses are non-tender. Pupils are equal and reactive. The nares are patent. The oropharynx is clear without lesions.
NECK: Supple without lymphadenopathy. Thyroid average size, without nodules.
HEART: Regular rate and rhythm.
LUNGS: CTA. No crackles or wheezes are heard.
ABDOMEN: Soft, non-tender, with good bowel sounds heard. The inguinal area is normal.
EXTREMITIES: Without cyanosis, clubbing, or edema. +2 DTR.
NEUROLOGICAL: Gross nonfocal. Denies HA, visual disturbances
Skin: Warm and dry, with no rash. Neg CVA tenderness.
Fetus: Bimanual exam presents as approximately 9 weeks of gestation. FHTs 150s-160s. No fetal movement. US performed by MSV CNM – estimated gestational age 9 weeks 2 days. EDD 11/8/2015.
Urinalysis: neg protein, neg glucose
Assessment (A)
30 yo G1P0 IUP 9w2d weeks by early U/S.
Mild nausea of pregnancy.
Family history of diabetes
Plan (P)
Diagnostics
– New OB Labs – T&S, CBC, G/C, RPR, Rubella, HBsAg, HIV, urine culture, HgbA1C
– Pap smear at age 21 yo per ACOG guidelines
– Fetal Genetic Screening – after counseling regarding options, pt has declined genetic screening (NT, 1st-trimester screen, NIPT)
– Cystic Fibrosis Screen
Treatment
– Daily PNV with folic acid
– Offer TDAP between 24-36 wks. Offer flu vaccine when available.
– Continue exercise as tolerated; walking, yoga, swimming, light weight-bearing
– Adequate rest & hydration
Education:
-Nausea and vomiting: Small, frequent meals, crackers & ginger ale, ginger, Sea-bands (acupressure), Vit B6 & Unisom
-Exercise- counseled regarding the importance of exercise and safe fitness level
-Counseled regarding nutrition: The patient will attempt to include lean protein, dairy, and vegetables.
-Weight gain: 25-35 lbs, varied, healthy diet with protein, fruit & veggies.
-TDAP & Flu vaccination recommendations
-Avoidance of Cat litter and gardening with gloves.
-Prenatal care schedule
-When to call the office and the emergency line number.
-Follow-up: RTO in 4 weeks &/or PRN
Example: OB Labor Progress Note
S: Patient c/o intermittent abdominal cramping. Rating pain 4/10 and managing pain well with nitrous oxide.
O: VSS, FHR baseline 135, + accelerations, intermittent late and variable decelerations, moderate variability.
Ctx: q 2-4mins, MVUs 156-217 per IUPC; AROM for clear fluid with IUPC placement;
vertex; SVE 4/60/-3
A/P: G1P0 IUP @ 38w3d
IOL for Oligohydramnios
Increase oxytocin per protocol
Category II tracing- Continuous electronic fetal monitoring, consider amnioinfusion if decelerations worsen.
GBS Positive- PCN per protocol
Pain: Epidural PRN. The patient would prefer to decline pain medication at this time, other than nitrous oxide.
Reassess in 2 hours or PRN- provide labor support and position changes;
Clear liquid diet r/t Cat II tracing
Example: OB Birth or Delivery Note
The patient was found to be completely dilated at 2119 and spontaneously bearing down at the peak of each contraction. After effectively pushing, the patient delivered a viable female infant over an intact perineum at 2123. The anterior shoulder delivered easily, and the postpartum oxytocin bolus was initiated. The cord was clamped x2 and cut after cessation of pulsation by the FOB. Apgars 8,9.
The placenta delivered spontaneously with gentle cord traction at 2132 and appeared intact upon visual inspection. The perineum was inspected and found to have a second-degree laceration repaired with 3-0 Vicryl in the usual fashion. EBL 350 ml, fundus u/2, and firm. Mom and baby were left in stable condition, skin to skin, attempting to breastfeed.
Ready to write smoother OB SOAP notes? Get the free template
OB Postpartum SOAP Note
S: Pt denies complaints. A moderate amount of lochia, no clots, voiding well, ambulating PRN, + flatus, no BM yet, denies N/V, breastfeeding without difficulty. Denies pain except intermittent cramping with breastfeeding, which she rates a 3/10 and states is manageable.
O:
Vital signs: T and Tmax, P, RR, BP (include ranges)
Lungs- CTAB
CV- RRR
ABD- Fundus firm, midline, u/2, non-tender
laceration- clean, dry, minimal edema
Ext- +1 pitting edema, +2 DTRs, neg calf pain
A:
24 year old now G2P2022, s/p NSVD doing well PPD#2
Prenatal labs: Rubella is immune and Rh positive.
Breastfeeding
Pain well controlled
P:
- Routine postpartum care
- Rx: Ibuprofen 600mg PO q 6 hours; Tylenol 1000mg PO q 6 hours PRN for breakthrough pain
- Colace daily
- Micronor for contraception to start at three weeks
- Lactation consult prior to Discharge
- Discharge home
- Pelvic rest, no heavy lifting for six weeks
- Follow up in 2 weeks for postpartum depression clinic and six weeks for Postpartum visit with Dr. _____ or CNM ______
SOAP Notes in the Medical Field
SOAP notes are a critical documentation tool in healthcare, essential for both students and professionals. Using well-crafted SOAP notes, especially in obstetrics, supports accurate patient care and clinical communication. As a certified nurse-midwife, I rely on these notes daily and have refined them into a reliable system.
