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Nursing Soap Note Template
Section 1: Subjective Data
1. 1. Chief complaint
2. 2. History of present illness
3. 3. History of past illness
4. 4. Social History (e.g., does the patient smoke/ do enough sports, etc.)
5. 5. Family History
6. 6. Review of Systems
7. 7. Is the patient taking any medication?
8. 8. Does the patient have any allergies?
Section 2: Objective Data
1. 1. Age
2. 2. Height (in inches)
3. 3. Weight (in lbs)
4. 4. BMI
5. 5. Gender
6. 6. General Appearance
7. 7. Blood Pressure
8. 8. Body temperature
9. 9. Any different appearances regarding eyes, ears, nose, throat?
10. 10. Respiratory
11. 11. Cardiovascular
12. 12. Integument/ Lymphatic Inspection
13. 13. Laboratory Results
Section 3: Assessment
1. 1. General Observations
2. 2. Differential Diagnosis
Section 4: Plan
1. 1. Any other notes