Nursing Notes Template

SOAP - Standardized Documentation Template for Patient Care

SOAP Documentation Format

S - Subjective Patient's reported symptoms, complaints, and concerns in their own words
O - Objective Measurable, observable data: vital signs, physical exam, lab results
A - Assessment Clinical judgment, diagnosis, and evaluation of patient's condition
P - Plan Care plan, interventions, medications, and follow-up instructions
S

Subjective

Patient's reported symptoms, feelings, and concerns

O

Objective

Measurable, observable clinical data

Vital Signs

Physical Assessment

Laboratory / Diagnostic Results

A

Assessment

Clinical judgment and problem identification

P

Plan

Interventions and care plan

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