Nursing care
SOAP note in nursing: what goes in each letter, a filled example and SOAPIE
Written and reviewed by Nicole Ramirez, BSN, RN, CMSRN · 4 min read · Updated November 2026
Short answer
In nursing, a SOAP note is a problem-focused progress note in four parts: Subjective (what the client says), Objective (what you measure or observe), Assessment (your interpretation of the problem), and Plan (what happens next). SOAPIE adds Intervention and Evaluation, so the note also records what you did and how the client responded.
What SOAP stands for and where it came from
SOAP stands for subjective, objective, assessment and plan. The StatPearls review of SOAP notes credits Larry Weed with the structure about 50 years ago, as part of problem-oriented records, and describes it as a checklist and a framework for clinical reasoning as well as a way to organize information.
Prescribers use SOAP for visit notes, while nurses usually write one SOAP or SOAPIE note per problem, such as acute pain or impaired mobility. The order matters: you collect data first, interpret it second, and only then plan. A plan with no data above it is a guess.
SOAP note nursing template
Use the rows below as your template. The first four letters are SOAP; the last two turn it into SOAPIE, which Open RN's Nursing Fundamentals text lists as a standard nursing format. Keep each part short and keep data in the letter where it belongs.
| Letter | What belongs here | Example phrase |
|---|---|---|
| S: Subjective | What the client or family reports, in their words | States 'it burns when I move' |
| O: Objective | Measured or observed data: vital signs, exam findings, labs, intake and output | Incision edges approximated, no drainage, pulse 102 |
| A: Assessment | Your interpretation of S and O, stated as a nursing problem | Acute pain related to surgical incision |
| P: Plan | Goal and planned nursing actions with a time frame | Pain at or below client's goal within 1 hour of intervention |
| I: Intervention | What you actually did | Repositioned, gave prescribed analgesic, taught splinting |
| E: Evaluation | Client response measured against the plan | Rates pain 3 out of 10 at 1 hour; goal met |
Filled SOAPIE example: post-op day 1
Hypothetical client for practice: S: 'My belly hurts too much to get up, about an 8 out of 10.' O: Day 1 after abdominal surgery, guarding when turning, pulse 104, blood pressure 138/86, respirations 22 and shallow, incision dry and intact. A: Acute pain related to surgical incision, limiting mobility and deep breathing.
P: Pain at or below the client's stated goal of 4 within 1 hour; walk in the hall by evening. I: Gave prescribed analgesic, repositioned with a pillow splint, taught splinting for coughing and moving. E: At 1 hour rates pain 3 out of 10, pulse 88, respirations 18 and deeper, walked to the doorway with assistance. Goal met; plan to walk in the hall after next dose.
SOAP vs SOAPIE vs DAR
SOAP ends at the plan, so it records intent but not what happened. SOAPIE closes the loop by adding the intervention and the evaluation, which is why many nursing programs prefer it: the note shows the whole nursing process for one problem in one place.
DAR, also called focus charting, compresses the same idea into data, action and response. It is shorter because assessment and plan are folded into the data and action lines. If your facility uses DAR, the reasoning is the same; only the headings change.
Mistakes that sink a SOAP note
The commonest error is misfiled data. A pain rating the client gives is subjective even though it is a number; a quote placed under O is wrong. Open RN defines objective data as findings others can observe and reproduce, so client anxiety belongs in O only as observed behavior, such as pacing or a shaky voice.
Other frequent errors: a medical diagnosis such as appendectomy written as the assessment, a plan with no time frame so it cannot be evaluated, a subjective section padded with the whole history, and an evaluation that says better without numbers. Each one breaks the chain from data to decision that the format exists to show.
Sources and further reading
StatPearls: SOAP Notes (Podder, Lew, Ghassemzadeh), Europe PMC record. SOAP definition, Larry Weed origin about 50 years ago, role as checklist and cognitive framework for clinical reasoning.
Open RN Nursing Fundamentals: Documentation. SOAPIE components and DAR (data, action, response) focus notes as nursing formats.
Open RN Nursing Fundamentals: Assessment. Subjective data in the client's words versus objective data that others can observe and reproduce.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our fundamentals practice questions are the closest set to what this page covers.
Common questions
What does SOAP stand for in nursing?
Subjective, objective, assessment and plan. Subjective is what the client reports, objective is what you measure or observe, assessment is your interpretation, and plan is what happens next. The structure is credited to Larry Weed's problem-oriented record.
How do nurses write a SOAP note?
Pick one problem. Write the client's own words under S, measured findings under O, the nursing problem they point to under A, and a time-limited goal with actions under P. In SOAPIE, add what you did under I and the measured response under E.
What is the difference between SOAP and SOAPIE?
SOAPIE adds Intervention and Evaluation to the four SOAP parts. SOAP shows the plan; SOAPIE also records what was done and whether it worked, so the note covers the full nursing process for that problem.
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