SOAP Notes for Nurse Practitioner Template

What as a Nursing SOAP Notes Template?

SOAP Notes are commonly used by nurse practitioners all over the world for recording all kinds of clinical documentation. This template has the four sections of SOAP Notes laid out for you already, with space for you to fill them in as you interact with your patient, as well as space for you to fill in your patient’s details.

The SOAP acronym stands for the four sections of the note: Subjective, Objective, Assessment and Plan.

Let’s break each section down to see why SOAP Notes are so widespread across the globe, and how you can incorporate SOAP Notes into your nursing practice using our nursing SOAP Notes template.

Subjective

This is where you write key points related to your patient’s subjective experience. This might include how they describe their presenting complaint, their medical and family history, their demographics and social history, allergies and current medications, and any other pertinent information they share with you about their subjective experience.

Objective

The objective section of the SOAP note is for the information you can measure and observe. Objective information on your patient might include their vital signs, appearance, histology, radiology, or physical examination results.

Assessment

This is where you can write your conclusions on the patient’s present condition based on the subjective and objective information you gathered in the first two sections. Depending on the situation and your own style, this might take the form of a primary diagnosis with differential diagnoses, or could just be a holistic summary of the patient’s issues supported by subjective and objective evidence.

Plan

What are the next steps based on the issues you have identified for your patient? The Plan section is where you write down your plan for the patient, which might include the immediate actions you took in response to their issue, the material you provided, referrals you made, or any medications you prescribed.

How to Use This SOAP Note Template for Nursing

Just follow these easy steps to start incorporating this handy nursing SOAP Note template into your nursing practice.

1. Get the template

This template can either be downloaded as a PDF or used within the Carepatron workspace (check out our explainer video if you’re not sure how to do this). If you are using the PDF version, simply hit download and edit the PDF digitally, or print it out and write on the paper copy by hand.

2. Patient Info

As we’re sure you know, before you start making your clinical notes- you need to ensure you’ve got the right patient! Filling in their name, date of birth, and optional identifier before you get into the rest of the template is a simple way to help you do this.

3. Get note-taking!

Start out with the Subjective section and continue working down the body of the template. The amount of time you spend on each section depends on you and your clinical judgment of what is relevant.

4. File your notes somewhere safe, secure, and accessible

Once you’ve completed the template, the final thing to do is ensure you file the finished document somewhere secure, as is required under HIPAA. This place should also be somewhere it can be easily accessed by the rest of your patient’s team. By using the PDF in its digital version or in the Carepatron workspace, you can be sure your notes will be secure, accessible, and safely stored.

Who Can Use this Nursing Template?

While this tool was designed with nurse practitioners in mind, ward nurses, theatre nurses, specialist nurses, nursing students or trainee nurses could definitely benefit from using this nursing SOAP Notes template as well.

If you have access to a computer while you are caring for patients, this template can be used within the Carepatron workspace or in a digital PDF format. If not, you can still use this template- just print it out and write straight onto the paper copy. To digitally store this note in the future, you can always scan it back into the computer and keep a digital copy that way.

This template can be used wherever you need to take clinical notes, whether that is in an initial assessment of a patient or as part of your regular nursing duties- the SOAP notes format is flexible enough to be used in many different situations or adapted to different note-taking styles.

Why is This Template Useful for Nurse Practitioners?

Make your note-taking more efficient

Nurses are under huge pressure to keep consistent records of the care they provide. Some nurses or nurse practitioners also need to keep a record of the medications they administer or prescribe, as well as any important results from all the interactions they have with their patients throughout what can be very busy and long shifts! With all that note-taking to do, using a premade template can help make sure your notes are consistent, comprehensive, and accurate.

Risk management

With the amount of work that nurses are often expected to get through in a shift, it can be very difficult to remember the details of every single patient interaction. Additionally, when you are under time pressure in a busy clinic, it can be easy to forget to ask a certain question that might come in useful in the future. Using a template that includes the commonly used SOAP sections, as well as spaces for patient information, is a great way to help make sure you’re covered legally if any problems arise.

Our simple format makes sharing easy

Using a pre-formatted and simply laid out notes template like our nursing SOAP Notes template makes sharing notes with others in your patient’s care team easy. The next time someone has to get information from your clinical notes, they’ll be able to find what they’re looking for in no time.

Benefits Of Using The Nursing SOAP Note Template

Have a consistent layout for your notes

Keeping your notes organized is the way to go, and what better way to organize your notes than to use a consistent layout in the form of our nursing SOAP Notes template.

Use our template as a cognitive framework

Using a SOAP template is great not just because it gives you a widely used format for your notes, but also because you can use the SOAP acronym as a tool to frame your patient interactions. Beginning with checking off the patient information at the top of the template, and then working your way through the rest of the SOAP headings is a great way to structure your nurse practitioner appointment sessions.

Make sure your notes are HIPAA compliant

As a nurse practitioner, you are legally required to keep accurate and timely notes regarding your patient interactions. You never know when you might need to provide evidence for the motivation behind your actions, and having well-structured SOAP notes is an excellent tool to make sure you’re meeting your note-taking obligations.

Aid your reflective practice

Constant improvement is part of being a nurse, and having a set of organized notes to look back on will help you to objectively reflect on your nursing practice.

Improve communication in your team

Making sure your notes can be easily interpreted by other members of your team is very important for the quality of your patient’s care. Using a standardized template like our nursing SOAP Notes template keeps your notes readable and easy for others to understand and pick up where you left off.