Nursing SOAP Note Template - Free Checklist

Nursing SOAP Note Template

About the Nursing SOAP Note Template

Nurses can use this SOAP note template to collect patient’s information for admission purposes. Use this checklist to take digital notes of the patient’s matters and needs. Collect information needed for medication by documenting the results of physical observations and laboratory tests.

Related categories

Preview of the template

Inspection

Subjective Data

Chief complaint:

History of present illness:

History of past illness:

Social History (e.g. does the patient smoke/ do enough sports,...)

Family History:

Review of Systems:

Is the patient taking any medication?

Does the patient have any allergies?

Objective Data

Age:

Height (in inches):

Weight (in lbs):

BMI:

Gender:

General Appearance:

Blood Pressure:

Body temperature:

Any different appearances regarding eyes, ears, nose, throat?

Respiratory:

Cardiovascular:

Integument/ Lymphatic Inspection:

Laboratory Results:

Assessment

General Observations:

Differential Diagnosis:

Plan

Any other notes:

Completion

Nurse's Name & Signature:

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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.