Nursing SOAP Note: Structure, ANA Nursing Process Alignment, SOAPIE Extensions, and Worked Examples

A nursing SOAP note is a structured clinical progress note format used by registered nurses (RNs), advanced practice registered nurses (APRNs), and clinical research nurses to document patient assessments, nursing diagnoses, care interventions, and clinical responses across inpatient, ambulatory, and clinical trial settings. Adapted from Dr. Lawrence Weed’s Problem-Oriented Medical Record (POMR) SOAP note framework (Subjective, Objective, Assessment, Plan)—and frequently expanded in acute nursing practice into SOAPIE (+ Intervention, Evaluation) or SOAPIER (+ Revision)—the nursing SOAP note operationalizes the American Nurses Association (ANA) five-step Nursing Process within electronic medical charting systems.

In nursing quality assurance, clinical research source documentation, and health informatics (identified by LOINC code 34746-8 for Nurse Progress note), a nursing SOAP note differs fundamentally from a physician or mid-level medical SOAP note: whereas a medical SOAP note formulates a pathophysiological medical differential diagnosis and orders pharmacologic or surgical treatments, a bedside nursing SOAP note documents the patient’s physiological and psychosocial human response to health conditions, standardized nursing diagnoses, autonomous and collaborative nursing interventions, and measurable patient outcomes.

What Is a SOAP Note in Nursing? Mapping SOAP and SOAPIE to the ANA Nursing Process

The American Nurses Association (ANA) defines the Nursing Process as a five-step iterative framework: Assessment, Diagnosis, Outcomes/Planning, Implementation, and Evaluation. Because bedside nurses continuously execute interventions and evaluate physiological responses during a single shift, nursing informaticists and clinical educators commonly map the standard four-part SOAP note—or the six-part SOAPIE extension—directly to the five ANA steps and ANA-recognized standardized nursing terminologies (NANDA-I, NIC, and NOC):

SOAP / SOAPIE Component	ANA Nursing Process Step	Standardized Terminology	Required Clinical Nursing Content
S — Subjective	Step 1: Assessment (Subjective Data)	LOINC / SNOMED CT Findings	Verbalized patient symptoms, pain characteristics (PQRST or 0–10 numerical rating scale), functional concerns, family/caregiver statements, and health literacy barriers recorded in direct quotes where clinically significant.
O — Objective	Step 1: Assessment (Objective Data)	LOINC Vital Signs / Lab Codes, SNOMED CT Observable Entities	Measurable physical exam findings, vital signs trends, intake and output (I&O), IV site/line patency, wound/dressing appearance, safety risk scores (e.g., Morse Fall Scale, Braden Scale), and diagnostic lab values.
A — Assessment	Step 2: Nursing Diagnosis (Clinical Judgment)	NANDA International (NANDA-I) / ICNP	Synthesis of S and O data into a prioritized clinical nursing judgment or nursing diagnosis (Problem + Etiology/Related Factors + Defining Characteristics), clinical trajectory (improving, stable, deteriorating), and risk identification.
P — Plan	Step 3: Outcomes Identification & Planning	Nursing Outcomes Classification (NOC) & NIC	Measurable, time-bound patient outcome goals for the shift or care episode, planned nursing monitoring intervals, patient education goals, and provider notification thresholds.
I — Intervention (SOAPIE)	Step 4: Implementation	Nursing Interventions Classification (NIC)	Specific independent nursing actions (repositioning, airway clearance coaching, fall precautions) and interdependent/collaborative actions (PRN medication administration, provider SBAR escalation) performed during the encounter.
E — Evaluation (SOAPIE)	Step 5: Evaluation	NOC Outcome Rating Scales	Timestamped reassessment of the patient’s physiological or behavioral response following the intervention (e.g., pain score reassessment 30–60 minutes post-analgesic, SpO2 response to supplemental oxygen titration).

Note: In EHR templates that use a four-part SOAP structure rather than six-part SOAPIE, completed nursing interventions and post-intervention reassessment results are documented either inside the Plan (P) section (as actions taken plus ongoing plan) or integrated chronologically across Objective (O) and Assessment (A).

Reusable Nursing SOAP / SOAPIE Note Template

Clinical documentation integrity programs and nursing informatics committees design problem-focused nursing progress note templates that complement—rather than duplicate—discrete EHR flowsheet rows:

Date/Time of Note: [YYYY-MM-DD HH:MM] | Clinical Problem / Focus: [e.g., Postoperative Pain / Acute Hypoxemia / Fall Risk]

S (Subjective):
- Patient statement: "[Direct quote describing primary symptom or concern]"
- Pain / Symptom Assessment: Onset [time], Provocation/Palliation [factors], Quality [description], Region/Radiation [location], Severity [0-10 score], Timing [constant/intermittent].
- Patient/family understanding of care plan or expressed barriers.

O (Objective):
- Vital Signs: BP [mmHg], HR [bpm], RR [breaths/min], Temp [°C/°F], SpO2 [%] on [room air / O2 device & flow rate].
- Focused Physical Assessment: [Neurological, cardiovascular, respiratory, GI/GU, musculoskeletal, integumentary/wound findings relevant to the problem].
- Lines, Drains, & Airways: [IV access site appearance/patency, urinary catheter, surgical drains, dressings].
- Relevant Labs / Diagnostics & Safety Scales: [Pertinent lab values; Braden Scale / Morse Fall Scale score referenced from flowsheet].

A (Assessment):
- Nursing Clinical Judgment / NANDA-I Diagnosis: [Problem] related to [etiology] as evidenced by [subjective/objective defining characteristics].
- Clinical Trajectory: [Progressing toward expected outcome / Acute change in status requiring escalation].

P (Plan):
- Measurable Shift Outcome (NOC): Patient will demonstrate [specific measurable target] within [timeframe].
- Planned Nursing Care (NIC): [Monitoring frequency, non-pharmacologic & pharmacologic measures, safety precautions, provider notification parameters].

I (Intervention — if using SOAPIE):
- [Timestamped nursing interventions executed, PRN medications administered per MAR, SBAR communication to MD/NP/PA with provider name and orders received].

E (Evaluation — if using SOAPIE):
- [Timestamped reassessment of vital signs, symptom score, or clinical status demonstrating response to intervention].

Worked Nursing SOAP Note Examples (Inpatient & Clinical Research)

Example 1: Acute Inpatient Medical-Surgical Postoperative Nursing SOAPIE Note

The following example demonstrates an inpatient surgical unit nursing SOAPIE note documenting acute postoperative incisional pain and splinting on Postoperative Day 1 (POD 1) following laparoscopic cholecystectomy:

• Subjective (S): Patient awake and alert, states, “My right upper belly incisions hurt sharply whenever I try to take a deep breath or sit up at the edge of the bed.” Rates incisional pain at 7/10 on the 0–10 numerical rating scale (acceptable functional pain goal stated as <= 3/10). Denies nausea, dizziness, chest pain, or shortness of breath at rest.
• Objective (O): Vital signs at 08:15: BP 138/84 mmHg, HR 92 bpm (regular), RR 20 breaths/min (shallow with inspiratory splinting), Temp 37.1°C (98.8°F), SpO2 94% on room air. Lungs clear to auscultation in upper fields with diminished breath sounds at bilateral bases. Abdomen soft, non-distended; four laparoscopic port dressings dry and intact without erythema or exudate. Incentive spirometry (IS) volume averaging 1,000 mL (baseline target 2,000 mL). Right forearm 20G peripheral IV patent without infiltration.
• Assessment (A): Acute postoperative incisional pain and ineffective breathing pattern (inspiratory splinting) related to surgical abdominal wall incisions, as evidenced by reported 7/10 pain score, shallow respirations (RR 20), and reduced incentive spirometry volume (1,000 mL), placing the patient at elevated risk for postoperative atelectasis.
• Plan (P):
  1. Achieve patient-reported pain score <= 3/10 within 60 minutes of multimodal analgesic administration and maintain IS volumes >= 1,750 mL during shift.
  2. Administer scheduled and PRN multimodal analgesia per MAR prior to physical therapy mobilization.
  3. Instruct patient on pillow abdominal splinting during coughing, deep breathing, and incentive spirometry (10 breaths every hour while awake).
• Intervention (I): At 08:25, administered scheduled non-opioid analgesic and PRN oral analgesic per MAR after verifying respiratory status and sedation score (Pasero Opioid-Induced Sedation Scale = 1). Positioned bed at 30-degree semi-Fowler’s angle and provided folded blanket for abdominal incision splinting. Coached patient through 10 slow incentive spirometry breaths at 09:15 and assisted with dangling at bedside.
• Evaluation (E): At 09:20 (post-intervention reassessment), patient reports pain decreased to 2/10 during movement. Vital signs: BP 124/76 mmHg, HR 78 bpm, RR 16 breaths/min (unlabored), SpO2 98% on room air. Patient successfully achieved 1,800 mL on incentive spirometer x 10 repetitions without grimacing and tolerated sitting at bedside for 15 minutes without orthostatic symptoms.

Example 2: Clinical Research Nurse Infusion Monitoring SOAP Note

In interventional clinical trials, research nurses write narrative SOAP progress notes to corroborate electronic Case Report Form (eCRF) entries under ICH E6(R3) ALCOA+ source documentation standards:

• Subjective (S): Study participant (Subject ID 104-022, Cycle 2 Day 1 Investigational Product infusion) reports mild facial warmth after infusion initiation. States, “My cheeks feel slightly warm, but I have no itching, throat tightness, or trouble breathing.”
• Objective (O): Infusing Investigational Product at protocol-specified baseline rate via left antecubital peripheral IV. Vital signs at 10:20: BP 122/78 mmHg (pre-infusion baseline 120/76 mmHg), HR 82 bpm, RR 16 breaths/min, Temp 36.8°C, SpO2 99% on room air. Mild transient malar erythema noted on bilateral cheeks; zero urticaria, angioedema, wheezing, or stridor.
• Assessment (A): CTCAE v5.0 Grade 1 Infusion-Related Reaction (mild transient flushing only; intervention not indicated), non-serious, clinically stable.
• Plan (P): Maintained infusion at protocol-specified rate per protocol Section 6.4 Grade 1 management guidelines; notified Sub-Investigator Dr. Patel at 10:22 (verbal confirmation to continue current protocol monitoring). At 10:35 reassessment, facial warmth and erythema completely resolved; vital signs stable (BP 120/74 mmHg, HR 76 bpm, SpO2 99% RA). Logged Grade 1 adverse event in source AE log for eCRF transcription.

Quality Measurement, Legal Standards, and Common Nursing Charting Pitfalls

Nursing SOAP notes serve both as legal medical records and as source audit trails for hospital quality reporting programs such as the National Database of Nursing Quality Indicators (NDNQI) (tracking pressure injury prevention, fall prevention, CAUTI, and CLABSI bundles). To satisfy Joint Commission and state board of nursing documentation standards, nursing notes must avoid four common pitfalls:

• Vague, Non-Quantifiable Phrases: Replace conclusory statements like “Patient had a good shift,” “Resting comfortably,” or “Voiding adequately” with objective metrics (e.g., “Voided 450 mL clear yellow urine via urinal at 14:00”).
• Omitting the Post-Intervention Evaluation (Closing the Loop): Documenting a high pain score, fever, or abnormal blood pressure along with an intervention (such as a PRN medication or fluid bolus) without recording a timestamped reassessment leaves an open clinical loop in medical-legal and quality audits.
• Unattributed Provider Escalations: When documenting an acute change in patient condition, always record the exact timestamp, the full name and credentials of the physician/NP/PA notified, the clinical SBAR summary communicated, and the exact response or orders received—never write merely “MD aware.”
• Flowsheet Contradictions via Copy-Forward: Copying forward a prior shift’s physical exam narrative in the SOAP note that contradicts current discrete EHR flowsheet values (for example, pasting “skin intact” when the wound flowsheet documents a Stage 2 sacral pressure injury) compromises clinical handoffs and regulatory audit integrity.