Nursing SOAP Note

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Nursing SOAP Note

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?

Yes No

Does the patient have any allergies?

Yes No N/A

Objective Data

Age:

Height (in inches):

Weight (in lbs):

BMI:

Gender:

Male Female

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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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.