SOAP charting is a structured method nurses use to document patient encounters by organizing information into four sections: Subjective, Objective, Assessment, and Plan. It gives every note a consistent logical flow, moving from what the patient reports, to what the nurse observes, to a clinical interpretation, to the next steps. The format was developed in the late 1960s by physician Larry Weed, who saw that disorganized medical records made it nearly impossible to track a patient’s problems over time. His solution, originally published in a landmark 1968 paper in the New England Journal of Medicine, became one of the most widely used documentation frameworks in healthcare.
The Four Sections of a SOAP Note
Each letter in SOAP represents a distinct type of information. Keeping them separate is the entire point of the format: it prevents subjective impressions from being confused with measurable data and ensures that every note moves toward a concrete plan.
Subjective (S)
This section captures what the patient tells you in their own words. It includes their chief complaint, a description of symptoms (location, duration, severity, what makes it better or worse), relevant medical history they share, and any concerns they raise. If a patient says “my pain is a 7 out of 10 and it gets worse when I walk,” that belongs here. Family members or caregivers can also contribute subjective information when the patient cannot communicate. The key distinction is that nothing in this section comes from your own observations or measurements.
Objective (O)
The objective section is everything you can measure, observe, or verify. Vital signs, physical assessment findings, lab results, wound appearance, intake and output numbers, and behavioral observations all go here. If another clinician could independently confirm it, it’s objective data. For example, noting that a surgical site has mild redness and no drainage is objective. Saying the patient “seems to be healing well” is an interpretation and belongs elsewhere.
Assessment (A)
This is where clinical reasoning happens. You take the subjective and objective information and interpret it. In nursing, this often takes the form of a nursing diagnosis or a summary of the patient’s current status relative to their care goals. Is the pain controlled? Is the wound improving or worsening? Is a new problem developing? The assessment connects the dots between what the patient reported and what you found on examination.
Plan (P)
The plan outlines what happens next. It can include changes to the care plan, scheduled interventions, patient education provided or needed, referrals, follow-up assessments, and discharge planning. A strong plan section is specific and actionable. Rather than writing “continue to monitor,” it states what you’re monitoring, how often, and what would trigger a change in approach.
Why SOAP Notes Are Structured This Way
Larry Weed created this format because he was frustrated by the state of medical records in the 1960s. As he described it, charts were “a bunch of scribbles” with no logical organization, making it difficult for any provider to pick up where another left off. His problem-oriented medical record system organized documentation around each of a patient’s active problems, with SOAP notes tracking progress on each one.
The format forces a discipline that mirrors the scientific method: gather data (S and O), form a hypothesis about what’s happening (A), and decide on a course of action (P). This structure isn’t just organizational preference. A multicenter study comparing structured documentation to unstructured notes found that structured formats scored significantly higher on documentation quality, with a 12.8-point improvement on a standardized quality scale. Structured notes were also rated as more concise and clearer, which matters when multiple providers need to quickly understand a patient’s situation.
Expanded Versions: SOAPE, SOAPIE, and SOAPIER
One limitation of the basic SOAP format is that it doesn’t explicitly prompt you to evaluate whether the plan actually worked. Several expanded versions address this gap. SOAPE adds an Evaluation section, serving as a built-in reminder to document whether interventions achieved the desired outcome. SOAPIE adds both Intervention (what was specifically done) and Evaluation. SOAPIER goes one step further with a Revision component for updating the plan when the evaluation shows the current approach isn’t working.
These extensions are particularly useful in nursing because the nursing process is inherently cyclical. You assess, plan, intervene, evaluate, and revise. The basic SOAP format captures the first two steps well but can leave the rest implicit. Many nursing programs teach one of these expanded versions to reinforce the habit of closing the loop on every intervention.
How SOAP Compares to Other Charting Methods
SOAP is not the only structured charting format nurses encounter. Two common alternatives are PIE charting and Focus (DAR) charting, and each organizes information differently.
- PIE charting uses three sections: Problem, Intervention, and Evaluation. It’s more streamlined than SOAP and integrates the care plan directly into daily documentation, which reduces redundancy. However, it doesn’t separate subjective from objective data, which can make it harder to trace the reasoning behind clinical decisions.
- Focus (DAR) charting organizes notes around a patient concern or focus, then documents the Data (both subjective and objective combined), Action taken, and Response. It’s flexible and works well for documenting specific events or changes in condition rather than routine assessments.
SOAP’s main advantage is its clear separation of patient-reported information from clinical findings, which reduces the risk of bias creeping into objective documentation. Its main drawback is that it can feel repetitive for routine entries and may not always prompt follow-through on whether interventions worked, which is why the expanded versions exist.
Writing Effective SOAP Notes
The most common problem with SOAP documentation is blurring the line between sections. Putting your interpretation into the Objective section, or mixing patient quotes into the Assessment, undermines the entire purpose of the framework. Each section should stand on its own. A reader should be able to look at just the Objective section and see only verifiable data, or read just the Subjective section and hear the patient’s perspective without the nurse’s analysis layered in.
Vague language is another frequent issue. Writing “patient doing well” in the Assessment doesn’t give the next nurse anything useful. Specificity matters: what improved, by how much, compared to when? Similarly, a Plan that says “continue current care” without detail forces the next provider to dig through previous notes to figure out what “current care” involves.
Electronic health record systems increasingly use built-in SOAP templates with structured fields, which helps with consistency. But templates can also encourage checkbox charting at the expense of meaningful narrative. The strongest SOAP notes combine structured data entry for vital signs and standard assessments with thoughtful free-text in the Assessment and Plan sections, where clinical reasoning needs to come through clearly.