Free SOAP Note Generator for Nurses
Generate complete nursing SOAP notes from your patient encounter keywords. Our AI understands vital signs, nursing assessments, medication administration, and care coordination documentation.
Nursing SOAP Notes
Nursing SOAP notes are essential for documenting patient encounters, communicating with the care team, and ensuring continuity of care. Unlike therapy or social work notes, nursing SOAP notes emphasize vital signs, physical assessment findings, medication administration, and clinical nursing interventions.
Section Guide for Nurses
S - Subjective
Document the patient's chief complaint, self-reported symptoms, pain levels (using a 0-10 scale), and relevant medical history. Include information provided by family members or caregivers when applicable.
O - Objective
Record vital signs (BP, HR, RR, temp, SpO2), physical assessment findings, wound assessments, intake/output, lab results, medication administration, and any nursing interventions performed. Use measurable, specific language.
A - Assessment
Provide nursing clinical judgment about the patient's current condition, response to treatment, and whether they are improving, stable, or declining. Connect observations to nursing diagnoses and care goals.
P - Plan
Outline nursing interventions, medication schedules, provider notifications needed, patient education provided, discharge planning tasks, and monitoring parameters. Include specific follow-up timeframes.
Common Nursing Assessment Tools
| Tool | Purpose |
|---|---|
| Braden Scale | Pressure injury risk assessment |
| Morse Fall Scale | Fall risk assessment |
| NRS / VAS | Pain assessment scales |
| GCS | Glasgow Coma Scale (neurological) |
| NIHSS | NIH Stroke Scale |
| NEWS2 | National Early Warning Score |
Nursing SOAP Note Example
S - Subjective
Patient is a 72-year-old male, post-operative day 2 following right total knee arthroplasty. He reported pain at the surgical site rated 6 out of 10, primarily with movement. He stated he felt "a little dizzy" when first standing this morning but that it resolved after sitting for a few minutes. He denied nausea, shortness of breath, or chest pain.
O - Objective
Vital signs: BP 138/82, HR 78, RR 16, Temp 98.6F, SpO2 96% on room air. Surgical wound was clean, dry, and intact with Steri-Strips in place. Mild edema noted around the right knee. Patient ambulated 50 feet in the hallway with a rolling walker and standby assist from physical therapy. Drain output was 45mL of serosanguinous fluid over the past 8 hours. Sequential compression devices in place bilaterally.
A - Assessment
Patient is progressing appropriately for post-operative day 2 following TKA. Pain is managed but would benefit from pre-medicating prior to physical therapy sessions. Orthostatic dizziness is likely positional and resolved with gradual position changes. Wound healing appears normal with no signs of infection. Fall risk remains elevated due to post-surgical mobility limitations.
P - Plan
Administer prescribed analgesic 30 minutes prior to next PT session. Continue fall precautions with bed alarm and non-slip footwear. Monitor wound site every shift and document drainage output. Encourage incentive spirometry 10 times hourly while awake. Initiate discharge planning with case manager. Physical therapy evaluation ordered for afternoon session with goal of stair navigation.
Frequently Asked Questions
How often should nurses write SOAP notes?
The frequency depends on your facility's policy and the patient's acuity. Generally, SOAP notes are written at least once per shift for inpatients, at each patient encounter in outpatient settings, and whenever there is a significant change in the patient's condition.
What is the difference between nursing notes and SOAP notes?
SOAP notes are a specific format for organizing nursing documentation. Other formats include narrative notes, DAR (Data, Action, Response), and focused charting. SOAP format is particularly useful for problem-oriented documentation and is widely recognized across healthcare disciplines.