→ Templates, examples, and common pitfalls to avoid
In NURS-6512N-47: Advanced Health Assessment, developing accurate, detailed, and clinically relevant SOAP notes is a core skill. These structured clinical notes help nurse practitioners and students communicate effectively, support diagnostic reasoning, and document care for legal and professional standards.
? What Is a SOAP Note?
SOAP stands for:
- Subjective: What the patient reports
- Objective: What you observe, measure, or assess
- Assessment: Your clinical interpretation
- Plan: Next steps in care
SOAP notes are used for everything from routine checkups to complex differential diagnoses and serve as vital documentation in electronic health records (EHRs).
✅ SOAP Note Template for APNs
Here’s a practical SOAP note outline tailored for NURS-6512N-47:
S – Subjective
- Chief Complaint (CC): “I’ve had a sore throat for 3 days.”
- History of Present Illness (HPI):
Onset, Location, Duration, Characteristics, Aggravating/Relieving factors, Treatment, Severity (OLDCARTS) - Past Medical History (PMH): Chronic conditions, surgeries
- Medications: Include OTC and herbal
- Allergies: Medication, food, environmental
- Social History: Tobacco, alcohol, drug use, occupation
- Family History: Relevant genetic risks
- Review of Systems (ROS): Systematic yes/no checklist by body system
O – Objective
- Vital Signs: BP, HR, Temp, RR, O2 sat
- Physical Exam Findings: Inspection, palpation, auscultation, percussion (by system)
- Labs/Imaging: Any recent or pending diagnostics
- General Appearance: “Alert and oriented, no distress.”
A – Assessment
- Primary Diagnosis: Include ICD-10 code
- Differential Diagnoses: 2–3 possible conditions with rationale
- Link subjective and objective findings to justify your clinical judgment
P – Plan
- Diagnostics: Labs, imaging
- Medications: Name, dose, route, frequency
- Education: What the patient should know/do
- Follow-up: When to return or call
- Referrals: If applicable
- Preventive care: Vaccines, screenings, lifestyle coaching
? SOAP Note Example: Acute Pharyngitis
S:
CC: “My throat hurts when I swallow.”
HPI: 32-year-old female with 3-day sore throat, worse in the morning, denies cough or congestion.
PMH: None. No current meds. Allergic to penicillin.
O:
Temp: 101.2°F; HR: 92; BP: 118/72
Tonsils enlarged with exudates, cervical lymphadenopathy, no nasal congestion. Rapid strep test positive.
A:
Acute streptococcal pharyngitis (ICD-10: J02.0)
DDx: Viral pharyngitis, mononucleosis
P:
Prescribed azithromycin 500 mg day 1, then 250 mg x4 days
Patient education on hydration and rest
Follow-up in 3 days if symptoms persist or worsen
❌ Common SOAP Note Mistakes to Avoid
| Mistake | Why It’s a Problem | Fix |
|---|---|---|
| ? Vague Language | “Patient feels sick” is non-specific | Use measurable descriptions: “Reports fatigue with 2-day history of 101°F fever” |
| ? Omitting ROS | Misses key diagnostic clues | Include full ROS, especially for new patients |
| ? Skipping Differentials | Weakens clinical reasoning | Include 2–3 possible diagnoses even if one is most likely |
| ? Lack of Plan Detail | “Follow up as needed” is insufficient | Always provide time frame and clinical indicators for return |
| ? Copy-paste errors | Can result in inaccurate documentation | Proofread every entry carefully |
? Tips for Success in NURS-6512N-47
- Review SOAP note rubrics provided in your assignments
- Practice with simulated patient cases
- Cross-check your assessments with evidence-based guidelines (e.g., UpToDate, CDC)
- Use clinical decision tools like the Centor Score or PHQ-9 when applicable
- Always document ethically and professionally—SOAP notes are legal records
? Final Thought: SOAP Notes Reflect Clinical Thinking
Your SOAP notes are not just documentation—they’re proof of your critical thinking, diagnostic reasoning, and communication skills as an emerging nurse practitioner. With practice, your notes will become one of your most powerful tools in advanced clinical practice.