The University of Texas at Arlington

College of Nursing
Soap Note Tips and Guidelines for the FNP Program
TIPS:

1. Review your Advanced Health Assessment Textbook for documentation of

the various components of a soap note. Focus on Subjective data components
and Review of System data components and Objective data components. It is
a primary reference source for soap note documentation.

2. If you have a positive complaint, it must be addressed in the physical exam,

assessment, and management of care plan. Remember the concept of balance.

3. It is not necessary to complete the entire Review of Systems (ROS) for an

interval visit. You should do a ROS for the presenting problem, Current
Medications (write the medication in prescription format, indicate why patient
is taking the medication, i.e., Topral x L 50 mg, 1 tab po/qd for HTN,
classification, etc.), (see sample table below
(Lisinopril 20mg 1 tab po daily
Indication: Essential Hypertension
Class: Antihypertensive: ACE inhibitor
Action: inhibits conversion of angiotensin I to angiotensin II precipitating the relaxation and widening of blood vessels thus
reducing systemic resistance and blood pressure
Common & Major S/E: dizziness, HA, diarrhea, cough, abdominal pain, photosensitivity, hypotension, elevated BUN and Cr,
fatigue, angioedema, Stevens-Johnson syndrome, hyperkalemia, renal toxicity, URI, neutropenia, hepatotoxicity, pancreatitis,
neutropenia, SIADH, hepatotoxicity, toxic epidermal necrolysis, pancreatitis.
Patient Education: Take this medication with a full glass of water. Do not take if you have a history of angioedema. Take with
food if you experience stomach upset. Keep taking this medication even if you feel better; most often HTN has no symptoms.
Monitor your BP daily at home. (Epocrates, 2017) )
and status of concurrent health problems. Status of pertinent past medical history,
family history, personal and social history should be addressed. Your history should
be focused.

4. “Rule out” diagnoses are those diagnoses that are most probable and must be
addressed in the plan (Ex: What do I need to do to rule this out?). A “Rule
out” requires an action: diagnostic orders and/or laboratory orders and/or
consults and/or referrals and/or other, as applicable. Currently most providers
use differentials instead of Rule Outs.
Differential diagnoses are ones that you considered with the patient’s Chief
Complaint and history but through reasoning decided against in favor of the
one you chose as Medical Diagnosis.

1
 Family history, personal history and social history may offer a contribution of
a possible differential diagnosis. It is not addressed in the plan as it is not one
of your “most likely”.

5. You may not cite a clinical guideline textbook, such as Collins-Bride or

Uphold and Graham, or any other clinical guideline as your reference for the
pathophysiology. A pathophysiology textbook is always the best reference.
You may cite a clinical guideline for rationale for your management of care
plan. All sources must be referenced according to APA format.

6. When you are doing your Review of Systems, the “general” category includes
symptoms such as fever, malaise, fatigue, night sweats, weight change. It
does not include any objective information such as “alert”, “oriented”, “good
historian”, etc.

7. When you are giving the rationale for medication usage, the expectation is to explain
the drug’s category and pharmacokinetic action (i.e., third generation cephalosporin
antibiotic and is used primarily for gram positive organisms), and why the patient has
been prescribed the particular medication. This is for OTC, Vitamins, Minerals,
Herbs also.

8. The note should accurately reflect the client encounter, the diagnoses made,
differentials and the recommended nursing/medical management of care.
Standardized chart forms, checklist, etc., utilized in the clinic setting will not be
accepted. (See Sample Format on next page)

10. All SOAP Notes should be on a different problem or need. All SOAP notes should
reflect the content/medical plan of care respective to the course. DO NOT use the
same SOAP Note from another course or previous course or another student’s SOAP
submission.

11. All SOAP notes must include rationale with the subsequent pathophysiology and
references regarding the selected management of care plan. This portion of the SOAP
note justifies your critical decision-making (i.e., why a calcium channel blocker was
chosen instead of an A. C. E. inhibitor or explanation as to why an asymptomatic
urinary tract infection was not treated.) Do not simply cite protocol resources but

2
 briefly describe the steps behind your management decisions. Reference rationale
and pathophysiology according to APA format.

12. Do not address a pathophysiology disorder you have already addressed in a Major
CDM or SOAP note. Select another patient to do a SOAP note on or address a
different major health problem/disease.

13. Nursing diagnoses can be health maintenance or social issue as well as a problem or
need. Example Format: Problem-focused diagnosis related to __________(related
factors) as evidenced by __________(defining characteristics). Example: Anxiety
related to situational stress (related factors) as evidenced by restlessness, insomnia,
(defining characteristics).
Medical diagnosis will be what you are diagnosing as their current and/or ongoing
problem.
Differential diagnoses are one that you consider as possibilities with the
patient’s Chief Complaint: as you are taking the subjective data, i.e., history,
current medication, ROS, and doing the physical exam. Example: You
diagnosed strep throat because the test was positive, but you had differentials
of viral illness, allergic post nasal drainage, ….

14. Screen needs, counseling needs, and immunization/chemo needs should be based on
the EPSS tool for the patient’s age, gender, sex, and race.
Screening, counseling, and immunization/chemo deficits are those that you have
found are in need.
Dr. Sara Moore states, “You will find in practice that individuals will spend all their
time putting out health care fires, when if they invested in their routine health care
needs they would spend less time in the clinic for sick visits.  So, taking the time to
empower the patient and family when you have them in front of you (even if it is for
a sick visit) may increase their health care participation thru out the year.”

3
Sample SOAP Note Format:

Patient Initials:________________ Date of Visit:__________________________

Patient Gender, Age, Race, Marital Status, DOB, Education level, Occupation, Source –
Reliability? __________________________

Preceptor name and title & Agency name and complete address:_____________________

S- Patient’s subjective data base as pertinent to the encounter and Health Promotion/Health
Maintenance/Assessment

O - Patient’s objective data base as pertinent to the encounter i.e., physical

examination, laboratory or diagnostic tests (if results are available at the time of visit)

A - Pertinent Positives; Pertinent Negatives

Medical diagnosis(es) – ICD-10 Codes
Any rule-outs (R/O) – ICD-10 Codes
Any differentials – ICD-10 Codes
Nursing diagnosis(es)

P - * Diagnostic studies and/or laboratory tests

* Medical Therapeutics/Non Therapeutics and/or Nursing Therapeutics, Prescriptions-
as it is ordered/prescribed
*Identify/distinguish what was ordered/implemented for the patient on the day
patient is seen
* Identify/distinguish expectations of future management of care plans, as
applicable
* Patient Education- Identify what was taught to patient on the day of the visit/what
may be needed for future visits
* Counseling- Identify the counseling implemented for the patient on the day of the visit
* Health Promotion/Health Maintenance Plan (Refer to Adult Management Format).
*Health Profile components: identify same day and/or future
*Alteration in Heath Prevention RT components: identify same day and/or
future
* Referral- identify same day and/or future- purpose/rationale
* Consults- identify same day and/or future- purpose/rationale
* Follow-up appointments- purpose/reason
* Prevention Plan-Identify what is ordered/completed on the day of the patient visit
based on the data from the Health Promotion profile

4
=====================================================================
* Rationale to follow each components/treatment in the management of care plan with
appropriate references in APA format.
* Pathophysiology for major diagnosis(es) with references – 2 (Two); relate to patient
*Clinical Guideline-should be an evidenced-based research article from evidenced-based
research article from peer-reviewed medical or APN peer-reviewed journal
* References - APA format, a minimum of 3-4 references, i.e. primary course textbook, a
pathophysiology book, a pharmacology book, etc. of which one must be an evidenced-
based research article from peer-reviewed medical or APN peer-reviewed journal
* Note: Appropriately label each portion. Refer to AHA for format of data collection.
* Note: Provide appropriate identifying information on patient – refer to AHA outline.
* Note: Reflection: How would you manage this patient differently if it were your own
practice? Compare the preventive education given to the patient in the clinic to what you
would propose if the patient were seen in the clinic to what you would propose if the
patient were seen in your office. The above plan needs to be specific to your patient.

TIPS for a few Specifics related to Documentation:

1. CC: in patient’s own words.

2. HPI: include the eight components, i.e., onset, location, quality,
severity/quantity, etc.
3. Current Health: Medication-written in prescription format –the typical dose
prescribes with why taking and classification, Mode of Action (see data
above) ; Allergies: the reaction; Last PE/screening: results; LMP & Birth
control: Birth control refers to the male patient as well as the female, as
applicable.
4. PMH: Childhood illnesses; adult illnesses; trauma; OB Hx/Sexual Hx: sexual
Hx refers to both male and female patients; Emotional/Psych HX: depression,
anxiety, etc. as applicable.
5. Family Hx: covers parents, grandparents, siblings, others family members as
applicable.
6. Personal and Social history: follow the format in AHA textbook
7. ROS: use the standard outline/format as on SOAP Template/AHA textbook;
for systems not needing data coverage because it does not apply to the CC
and/or your differentials put NA-does not apply at all or Deferred –not needed
at this time, can be delayed until another time as related to CC/differentials.
Separate and label each component of: Skin/Hair/Nails such as—Skin and
then data; Hair and then data; Nails and then data; HEENT such as- Head and
then data; Eyes and then data; Ears and then data; Nose and then data; Sinuses
and then data; Throat and then data; Breast; CV/peripheral- CV and then data;
peripheral vascular and then data; Genitalia/Rectum- Genitalia and then data;

5
 Rectum and then data; Lymph/Heme/Endocrine-Lymph and then data; Heme
and then data; Endocrine and then data; Psych is a separate system does not
go with Neuro that is also a separate system.
8. Physical Exam: use the standard outline as on the SOAP note Template/AHA
textbook; BMI-interpret i.e, obesity, etc.; Separate and label each component
of: Skin/Hair/Nails; HEENT, Sinuses; Breast/chest; CV/peripheral; Genitalia/
Rectum; Lymph/Heme/Endocrine, etc. Exam and document bil. for all
systems having 2 of – such as lungs, etc.
9. Diagnostics/Laboratory: Diagnostics refers to imaging/x-rays, etc.; Laboratory
refers to blood tests, cultures, etc.; - results available at the start of the patient
visit goes here with results and should be addressed in the management of
care plan for positives.
10. Management of Care Plan: Diagnostics- refers to ordering x-rays, CT scans,
MRI, rapid strep screening, etc. or indicate there is no need at this visit and
why or will/may be ordered in the future and why. Laboratory: ordering of
labs on the day of the visit with rationale or will need in the future and why.
11. Pathophysiology-cover in detail-up to 2 pages-the more details helps with
better understanding the diagnosis in the future.
12. Clinical guideline: copy the first page or the second page of the guideline; if
providing a link-be specific as to the reference you are referring, put reference
source using APA. Follow/implement the guidelines recommendation for
management of care and/or components of care.
13. Be specific with – amounts/sizes i.e, sodas-2 20oz. bottles of 7-Up every day,
, coffee, alcohol-beer, wine, whiskey; amounts and history of tobacco-what
type of tobacco product is used-cigarettes, pipes, etc.; what type of healthy
diet-DASH, etc.