SOAP Note Template Nurse Practitioner Students Can Use

A SOAP note template nurse practitioner students can follow gives every patient note the same four sections: Subjective, Objective, Assessment and Plan. Your preceptor and your faculty read your notes to see how you think through a case, so a clear note is a great way to show what you’ve learned. Below you’ll find a template to copy and a complete example for a fictional primary care patient. We’ll also go through the mistakes preceptors and faculty point out, and how to keep school assignments free of anything that identifies a patient.

TL;DR

• Start from the SOAP note template nurse practitioner students can adapt to any visit, and fill in only what applies.
• Subjective is what the patient tells you, Objective is what you find, Assessment is what you think and why, and Plan is what happens next.
• Show your reasoning and a differential in the Assessment, and tie every Plan item to a diagnosis.
• Leave every patient identifier out of school assignments, including names, record numbers and any date more specific than the year.
• The example below is a documentation model for students, not treatment advice.

What are the four parts of a SOAP note?

A SOAP note has four parts, and each one answers a question about the visit. In Subjective, you record what the patient told you. In Objective, you record what you observed, measured and tested. In Assessment, you explain what you think is going on and why, and in Plan, you describe what happens next. Each section builds on the one before it, so your reader can follow your reasoning from the first symptom to the follow-up visit.

The SOAP note template nurse practitioner students can copy

Use this template for school assignments, or compare it with the form your program or clinical site gives you.

Visit details

• Visit type and setting, such as an acute visit at a family practice clinic
• Patient’s age and sex, with no name, initials, birth date or record number
• Source of the history (the patient, a parent or an interpreter) and how reliable it seems

Subjective: what the patient tells you

• Chief complaint, in the patient’s own words and in quotation marks
• History of present illness: onset, location, duration, character, aggravating and relieving factors, radiation, timing and severity (OLDCARTS), plus treatments already tried
• Past medical and surgical history
• Medications with name, dose and frequency, including over-the-counter drugs and supplements
• Allergies, with the reaction
• Family and social history that relate to the visit, including tobacco, alcohol and drug use
• Review of systems: pertinent positives and negatives for each related body system

Pertinent negatives show your thinking. “Denies fever, vision changes and tooth pain” tells your reader you asked about the symptoms that would change your diagnosis.

Objective: what you observe and measure

• Vital signs and general appearance
• Physical exam by body system, focused on the complaint
• Results from today: point-of-care tests, labs and imaging

Describe findings instead of labeling them. “Tenderness over both maxillary sinuses” tells your preceptor what you found, while “sinus exam abnormal” doesn’t say what was abnormal.

Assessment: what you think is going on

• Diagnosis for each problem, with its ICD-10-CM code if your program asks for one
• The subjective and objective findings that support each diagnosis
• Differential diagnoses, with the reason each one is more or less likely

This is the section where your preceptor and faculty see how you think, so show your reasoning instead of naming a diagnosis alone.

Plan: what happens next

• Diagnostics: the tests you’d order, and why
• Therapeutics: each medication with name, dose, route, frequency and duration, plus any treatment without medication
• Patient education, and how the patient responded
• Referrals
• Follow-up, with return precautions: the symptoms that should bring the patient back sooner

Write a plan for each problem in your Assessment, so every item traces back to a diagnosis.

A SOAP note example for NP students

Here’s the SOAP note template nurse practitioner students can copy, filled in for one ordinary primary care visit. The patient is fictional, and this is a documentation example for students, not treatment advice. For real patients, follow your preceptor and current clinical guidelines. If your program asks you to cite sources, add them where you use them, the way this example does in parentheses.

Visit details: Acute visit at a family practice clinic. The patient is a 34-year-old woman and a reliable historian.

Subjective

• Chief complaint: “My face hurts and my nose is stuffed up.”
• History of present illness: Nasal congestion and pressure over both cheeks for 5 days, starting after her two children had colds. Dull pressure, 4 out of 10, worse when she bends forward. Thick yellow nasal discharge for 3 days, with postnasal drip and a mild cough at night. Highest temperature at home was 99.1°F. She feels slightly better today than yesterday. Saline nasal spray and hot showers help a little. She took ibuprofen 400 mg twice yesterday, with partial relief, and asks whether she needs an antibiotic.
• Medical history: No chronic conditions or surgeries. No asthma, stomach ulcers, bleeding problems, kidney disease or heart disease.
• Medications and allergies: No daily medications or supplements. No known drug allergies.
• Social history: Has never smoked or vaped. Drinks alcohol 1 to 2 times a week.
• Review of systems: Mild fatigue and a mild sore throat in the mornings. No chills, ear pain, tooth pain, vision changes, swelling around the eyes, shortness of breath, wheezing, severe headache or neck stiffness.

Objective

• Vital signs: Temperature 99.0°F (37.2°C) oral, blood pressure 118/76, heart rate 78, respiratory rate 16, oxygen saturation 98 percent on room air.
• General: Alert, well-appearing, in no distress.
• Face and eyes: Tender over both maxillary sinuses. No facial or periorbital swelling or redness. Conjunctivae clear, extraocular movements intact and painless.
• Ears, nose and throat: Tympanic membranes normal on both sides. Swollen, red nasal mucosa with thick yellow discharge. Mild redness of the posterior pharynx with postnasal drainage, and no tonsillar exudate. Teeth and gums normal, with no tenderness when the upper teeth are tapped.
• Neck and lungs: Neck supple, with no enlarged lymph nodes. Lungs clear on both sides, with no wheezes or crackles.

Assessment

• Acute viral rhinosinusitis, maxillary (ICD-10-CM J01.00). Five days of congestion, maxillary pressure and discolored discharge after colds at home, with maxillary tenderness and swollen nasal mucosa. She has no fever and is slightly improving. Her course doesn’t meet any of the CDC’s criteria for acute bacterial rhinosinusitis:
  • Severe symptoms for more than 3 to 4 days, such as a fever of 39°C (102°F) or higher with purulent discharge or facial pain
  • Symptoms for more than 10 days without improvement
  • Worsening after initial improvement
• Differential diagnoses:
  • Acute bacterial rhinosinusitis: less likely, for the reasons above.
  • Allergic rhinitis: less likely. No itchy eyes or sneezing spells, no seasonal pattern, and her symptoms began after a cold went through her household.
  • Dental infection: less likely. No tooth pain, and her teeth and gums are normal on exam.

Plan

• Diagnostics: No labs or imaging. Sinus x-rays aren’t routinely recommended (CDC).
• Therapeutics: No antibiotic. Watchful waiting, since this is an uncomplicated case with reliable follow-up (CDC). Saline nasal spray several times a day, a warm compress over the face and steam inhalation (CDC, MedlinePlus). Ibuprofen 400 mg by mouth every 6 hours as needed for facial pain, no more than 1,200 mg in 24 hours (over-the-counter label).
• Education: Explained that sinus infections are usually viral and often get better on their own without antibiotics. She agrees with watchful waiting and repeated the return precautions back in her own words.
• Follow-up: As needed. Return or call for any of these (CDC, MedlinePlus):
  • Symptoms that last more than 10 days without getting better
  • Symptoms that get worse after improving
  • A fever that lasts more than 3 to 4 days
  • A severe headache or severe facial pain
  • Any change in vision

How do you write a SOAP note for an NP visit?

Write it in the order you gathered the information, soon after the visit while the details are fresh:

1. Prepare. Review the chart, the reason for the visit and any recent results, so you know what to ask.
2. Write Subjective and Objective from the notes you took during the visit, following your site’s rules on what you can write down.
3. Present the case to your preceptor. If they teach with the One Minute Preceptor model, expect two questions first: what do you think is going on, and what evidence supports it? Your answers become your Assessment.
4. Write the Assessment and Plan with your preceptor’s input.
5. Check the note against the template and the mistakes below before you sign it or hand it in.

What mistakes do preceptors and faculty flag in SOAP notes?

These are problems preceptors and faculty point out in student notes, and each one has a simple fix:

• Mixing up Subjective and Objective. “Reports a fever at home” belongs in Subjective. “Temperature 99.0°F” belongs in Objective.
• A diagnosis with no reasoning or differential. Name the findings that support it and the other diagnoses you considered.
• A Plan that doesn’t match the Assessment. Every diagnosis needs a plan, and every item in the plan should trace back to a diagnosis.
• Vague medication orders. “Ibuprofen as needed” leaves out the dose, route, frequency and daily limit. Write the full order.
• Error-prone abbreviations and decimals. Write out “units”, since a “U” can be misread as a zero. Write “5 mg”, not “5.0 mg”, and “0.5 mg”, not “.5 mg”. The FDA warns that each of these mistakes can lead to a tenfold overdose.
• Template text that doesn’t match the visit. A normal exam carried forward, or a review of systems marked “all negative” when the patient reported a cough, makes your reader doubt the whole note.
• Labels instead of facts. Write “declined the flu vaccine” rather than “noncompliant”.

How do you keep patient identifiers out of SOAP note assignments?

Whichever SOAP note template nurse practitioner programs give you, remove anything that could identify the patient before a note goes into a school assignment, a discussion board or a study group. Your program and your clinical site set the rules for student work, so read both policies first.

The HIPAA Privacy Rule makes a good checklist. Its Safe Harbor method lists 18 types of identifiers to remove before health information counts as de-identified. These are the ones that tend to appear in student notes:

• Names, including the names of relatives, employers and household members
• Any place smaller than a state, such as a street address, city or zip code
• Every part of a date except the year, such as a birth date or visit date
• Ages over 89, which become “90 or older”
• Phone numbers, email addresses, and Social Security, medical record, health plan and account numbers
• Full-face photos and similar images
• Any other unique identifying number, characteristic or code

That last item is a reason to describe a rare condition or an unusual detail in general terms. Write the assignment version from your own de-identified notes rather than copying from the chart, and leave out initials too. Keep patient details off personal devices, cloud folders and AI tools unless your program and site approve them.

How do SOAP notes fit into your clinical hours?

The notes you write at your site come from patients you saw during your clinical hours, so they’re part of the record of your clinical education. The 2022 Standards for Quality Nurse Practitioner Education set a minimum of 750 direct patient care hours, and ANCC and AANPCB certification require at least 500 faculty-supervised clinical hours. The standards also ask programs to keep electronic logs or e-portfolios of your clinical encounters, which faculty review “for breadth, depth, and type.”

Whether charting time counts toward your hours depends on your program, so read our guide to what counts as clinical hours and ask your clinical coordinator when your handbook doesn’t say.

Writing in the real chart is your site’s decision. Medicare’s documentation rules let NPs, physicians and PAs review and verify notes that NP students write in the medical record, signing and dating them instead of documenting the visit again. A sample checklist in the national standards also asks preceptors to orient you to the site’s EHR before you see patients, so ask about charting early. Our tips for the first day of your clinical rotation cover how to clarify expectations with your preceptor.

Feedback from your preceptor is a great way to improve your notes, so ask them to review one with you early in the rotation. Our tips for working with clinical preceptors explain how to ask for feedback, and our guide to what a clinical preceptor is explains their role in your training.

Common SOAP note questions

What’s a good example of a SOAP note?

A good SOAP note is one your preceptor can follow from the chief complaint to the follow-up plan without asking you a single question. In the sinus visit example above, every finding is in the right section, the Assessment explains why the diagnosis fits, and each Plan item traces back to it.

Is there one SOAP note template nurse practitioner programs all use?

No. Programs and clinical sites often have their own forms and EHR templates, and the four SOAP sections stay the same in each one. Match your program’s rubric for school assignments and your site’s template in the chart.

How long should an NP SOAP note be?

Long enough to support your Assessment and Plan. A focused visit for one problem needs a focused note, while a new patient visit or an annual exam needs a full history and a head-to-toe exam. When your program’s rubric sets a length, follow it.

How is an NP SOAP note different from the SOAP notes nursing students write?

The four sections are the same. As an NP student, your Assessment names medical diagnoses with a differential, and your Plan lists the tests, prescriptions, referrals and follow-up you’d order. Your preceptor reviews that plan with you before anything happens.

Find a nurse practitioner preceptor for your next rotation

Every SOAP note starts with a preceptor who lets you care for their patients. If you’re still looking for a nurse practitioner preceptor, we can help. Clinical Match Me is a preceptor placement service for NP and PA students in every clinical specialty. Our founder is a nurse practitioner who struggled to find a preceptor as a student, and since 2014 we’ve helped more than 10,000 students find preceptors.

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