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NUR 634 SOAP Note Guide and Template Patient SOAP Note Charting Procedures S = Subjective O = Objective A = Assessment P = Plan Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it. Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing.

NUR 634 SOAP Note Guide and Template Patient SOAP Note Charting Procedures S = Subjective O = Objective A = Assessment P = Plan…