SOAP Notes

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EXAMPLE OUTPUT

SOAP CLINICAL NOTE

Patient:Margaret Sullivan | DOB 12/04/1948 | MRN-004821

Ward / Bed:4B General Medical — Bed 4

Date / Time:13/03/2026 10:30

S — SUBJECTIVE

“I can’t catch my breath and my chest feels tight. The pain is about a 6 out of 10.”

O — OBJECTIVE

Vitals:T 38.2 HR 98 BP 118/72 RR 22 SpO2 93% on 4L O2

Breathless at rest. Accessory muscle use noted. Reduced air entry right base. Alert and oriented x3.

A — ASSESSMENT

Community-acquired pneumonia — deteriorating respiratory status. NEWS2 score 5.

P — PLAN

MO notified — urgent review. O2 increased to 6L. Obs every 30 mins. CXR ordered. IV antibiotics continued.

Documented by:J. Chen RN — AHPRA: NMW0001234567

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Clinical Reference: The SOAP format (Subjective, Objective, Assessment, Plan) is a widely used structured documentation method in healthcare.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278(11):593–600.

SOAP NOTE

SSUBJECTIVE

What the patient tells you — symptoms and complaints in their own words

Patient's complaint / reported symptoms

OOBJECTIVE

What you observe and measure — vitals, physical findings, test results

Current Vitals

Physical Examination / Observations

Relevant Investigation Results

AASSESSMENT

Your clinical interpretation — what is happening and why

Clinical Assessment

PPLAN

What you and the team will do — interventions, referrals, monitoring

Plan of Care

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