Lumiform / Templates / Nursing SOAP Note

Nursing SOAP Note

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.

Downloaded 58 times

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 4000 expert-proofed templates

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

Nursing SOAP Note

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:

This template is also available in:

Previous template

Next template

Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.