Nursing SOAP Note

• Patient Name

• Assigned Medical Practitioner

• Conducted on

  Date
• Location
  Address

Subjective Data

• Chief complaint

• History of Present Illness

• Past Medical History

• Family History

• Social History

• Review of Systems

• Is the patient taking any medication?

  Yes

  No

• Please specify

• Patient has no allergies

  Yes

  No

  N/A

Objective Data

• Age

• Gender

  Male

  Female

• Height (in)

• Weight (lbs)

• BMI

Temperature

• Blood Pressure (BP)

• General Appearance

• EENT (Eyes, Ears, Nose, Throat)

• Cardiovascular

• Respiratory

• Integument/ Lymphatic Inspection

• Laboratory Results

Assessment

• General Observations

• Differential Diagnosis

Plan

• Nurse's notes

Completion

• Attending Nurse's Name & Signature

  Sign