SOAP Note Generator
Build a clean, structured SOAP note in minutes. Choose a nursing, primary care, mental health, or physical therapy template, fill in the Subjective, Objective, Assessment, and Plan, and export to Word. Free, no sign-up, and nothing leaves your browser.
Nursing SOAP note for a shift assessment or focused reassessment. Subjective captures the patient's reported symptoms; Objective captures your assessment findings and vitals.
What the patient tells you: chief complaint and history of present illness (onset, location, duration, character, aggravating and relieving factors, timing, severity), plus relevant past history, medications, and allergies. Use the patient's own words where useful.
What you measure and observe: vital signs, physical exam findings, mental status, range of motion, and any labs, imaging, or test results. Facts only, no interpretation.
Your clinical judgement: the working diagnosis or problem, a differential where relevant, and how the patient is progressing. This is where you synthesise the Subjective and Objective.
What happens next: diagnostics ordered, treatment and medications, patient education, referrals, and follow-up. Make each item specific and actionable.
Formatted SOAP note
Fill in the sections on the left, or load the worked example, to build your note.
Everything stays in your browser; nothing is uploaded. Do not enter real patient identifiers. Use de-identified initials only.
The Four Sections, and What Belongs in Each
The value of the SOAP format is discipline: it forces you to separate what the patient reports from what you observe, and what you think from what you will do. The single most common documentation error, mixing those four kinds of information, is exactly what the structure prevents. Keep each section pure and the clinical reasoning becomes legible to the next reader.
Subjective is the patient's story. Capture the chief complaint and the history of present illness: onset, location, duration, character, aggravating and relieving factors, timing, and severity. Pertinent negatives belong here too ("denies fever, denies nausea") because what the patient does not report is often as diagnostic as what they do. In a nursing note this is where the reported pain score and the patient's own description sit.
Objective is measured and observed data only: vital signs, the focused physical examination, mental status, range of motion, and any laboratory, imaging, or point-of-care results. The test for this section is simple: if it is an interpretation rather than an observation, it does not belong here, it belongs in the Assessment. The generator adds your entered vital signs to the top of this section automatically.
Assessment is where the two halves meet. State the working diagnosis or the active problem, a short differential where the picture is uncertain, and a judgement on trajectory (improving, stable, deteriorating). A one-line assessment that reads "abdominal pain" is a missed opportunity; "acute right-lower-quadrant pain, rule out appendicitis, pain inadequately controlled" tells the reader what you are thinking and why the plan follows.
Plan must be actionable. Every item needs enough detail to act on without you present: the diagnostic ordered, the drug with its dose and route, the education given, the referral made, and the explicit follow-up or reassessment timing. "Reassess pain in 30 minutes" is a plan; "monitor" is not. Where the situation is escalating, the plan is also where you record that you notified the provider.
Some settings extend the format to SOAPIE, adding Intervention and Evaluation to close the loop on the nursing process. If that is what your programme expects, document the actions you took and the patient's response as the final two steps of the Plan. If you are moving from the assessment into a full nursing care plan, the SOAP assessment feeds directly into your NANDA-I diagnosis and PES statement.
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Frequently Asked Questions
What are the 4 components of a SOAP note?
SOAP stands for Subjective, Objective, Assessment, and Plan. Subjective is what the patient reports: the chief complaint and history of present illness in their own words. Objective is what you measure and observe: vital signs, physical exam findings, and test results. Assessment is your clinical judgement: the working diagnosis, differential, and how the patient is progressing. Plan is what happens next: diagnostics, treatment, medications, education, referrals, and follow-up. The generator gives you a labelled field for each so nothing is left out.
How do you write a SOAP note for nursing?
A nursing SOAP note follows the same four headings but frames them around your assessment and the nursing process. Put the patient's reported symptoms and pain score in Subjective, your focused assessment findings and vitals in Objective, the clinical problem and your interpretation in Assessment, and the nursing actions, escalation, education, and reassessment timing in Plan. Select the nursing template in the tool and load the worked example to see a shift-note written this way.
What are common SOAP note mistakes?
The most common errors are mixing subjective and objective data (putting an interpretation in the Objective section, or a measured vital sign in Subjective), leaving the Assessment vague instead of naming a working diagnosis or problem, and writing a Plan that is not actionable (no dose, no timeframe, no follow-up). Others include copying forward stale information, omitting pertinent negatives, and documenting so briefly that the clinical reasoning cannot be followed. The tool's per-section prompts are written to keep each type of information in the right place.
How detailed should a SOAP note be?
Detailed enough that another clinician can pick up care without asking you what happened, and no longer. The history should capture onset, character, severity, and relevant negatives; the exam should record the pertinent positive and negative findings, not a head-to-toe recital; the assessment should state your reasoning; the plan should be specific and time-bound. Concise, well-organised notes are safer and faster to read than long ones padded with normal findings.
What is the difference between SOAP and SBAR?
SOAP is a documentation format for a clinical encounter, structured around Subjective, Objective, Assessment, and Plan. SBAR (Situation, Background, Assessment, Recommendation) is a communication tool for handover or escalation, designed to convey a concern quickly, for example when phoning a provider. You document an encounter in SOAP; you hand over or escalate in SBAR. Many nurses write the SOAP note during the shift and use SBAR to communicate a change in status.
Do nurses and doctors still write SOAP notes?
Yes. SOAP remains one of the most widely taught and used clinical documentation formats across nursing, medicine, therapy, and allied health, both on paper and inside electronic health records. Some settings use variants such as SOAPIE (adding Intervention and Evaluation) or a problem-oriented note, but the SOAP structure underneath is the same. It endures because separating what the patient says, what you find, what you think, and what you will do produces clear, defensible records.
Can I use ChatGPT to write SOAP notes?
A general chatbot can draft prose, but it can also invent findings, vitals, or diagnoses that were never observed, which is unacceptable in a clinical record and a documentation-integrity risk. This tool is not a language model: it is a structured template that formats exactly the information you enter, nothing more and nothing less. Your inputs stay in your browser and are never sent to a server, so it is safe to use for coursework and for organising your own documented findings.
Does the tool store my patient data?
No. Everything you type stays inside your browser and is never uploaded. Refreshing the page clears it. To keep a copy, use Copy to clipboard or export to Word. Do not enter real patient identifiers: use de-identified initials only, in line with confidentiality requirements.
Can I use this for a nursing school assignment?
Yes. The nursing template and worked example are built for students learning to document a focused assessment. Use it to structure your practice notes and case studies. If you have a full assignment, dissertation, or capstone that needs writing up to APA 7 standard, our nursing writing team can take it from there.
Related Resources
Nursing Care Plan Generator
Build a NANDA-I care plan with a PES diagnosis, NOC outcomes, and NIC interventions.
How to Write a SOAP Note (Guide)
A worked walkthrough of the four sections with a nursing example and SOAP vs SBAR.
PICOT Question Generator
Frame an evidence-based practice question for a nursing project or capstone.
Reviewed by
Dr. Sarah Mitchell
Dr. Sarah Mitchell holds a PhD in Biostatistics from Johns Hopkins Bloomberg School of Public Health and has over 15 years of experience in systematic review methodology and meta-analysis. She has authored or co-authored 40+ peer-reviewed publications in journals including the Journal of Clinical Epidemiology, BMC Medical Research Methodology, and Research Synthesis Methods. A former Cochrane Review Group statistician and current editorial board member of Systematic Reviews, Dr. Mitchell has supervised 200+ evidence synthesis projects across clinical medicine, public health, and social sciences. She reviews all Research Gold tools to ensure statistical accuracy and compliance with Cochrane Handbook and PRISMA 2020 standards.
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