Soap Note for Nursing

Subjective:

Patient presents with chief complaint of _____. Patient reports that the pain is a ___ out of ten and has been present for ____ weeks/months. patient denies any other symptoms associated with this complaint.

Objective:

On physical examination, patient appears to be in no distress. vital signs are stable and within normal limits. There is tenderness to palpation at _____ cm from the _____ spine. There is no guarding or rebound tenderness. Range of motion is within normal limits.

Assessment:

Based on the patient’s history and physical examination, it is most likely that the patient is suffering from _____. This is a condition characterized by _____.

Plan:

The patient will be started on _____ for pain relief. The patient will be advised to follow up with their primary care physician in _____ weeks/months. In the meantime, the patient will be instructed to return to the emergency department if they develop any new or worsening symptoms.

 

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