SOAP NOTE OBJECTIVE

The Objective section of the SOAP Note includes an examination of the vital signs, then a conduct a physical exam and document what you see.

Here’s what to structure the SOAP Note Objective section

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

objective soap note

Here are three examples of the SOAP Note Objective section

Soap note nursing Example 1

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

Soap note nursing Example 2

O.

Physical exam

VS: Temp-97.6, BP-100/67, HR-73, RR-22, O2 sat-100%, Height-4’13.5” (91stpercentile), Weight-78lbs (59thpercentile), BMI-16.7 (24thpercentile);

General Appearance: healthy-appearing, well-nourished, and well-developed

Cardiovascular– S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs Carotid Arteries: normal pulses bilaterally, no bruits present.

Respiratory- Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi

Gastrointestinal– No rigidity or guarding, no masses present,

Pulmonary—No difficulty in breathing or dyspnea

Diagnostic Tests

  • Demonstration of osseous erosion on CT scanning

Soap note nursing Example 3:

OBJECTIVE DATA:

            Physical Exam:

Vital signs: Vital Signs: Pulse 83 and regular Temp. 99F Resp. B/P 1st 120/72

Pulse Ox 98%, T 98.3 Orally; RR 16; non-labored; Wt: 165 lbs; Ht: 5’3; BMI 29.5

General: NAD, well-groomed

HEENT: No changes in vision or hearing. No history of glaucoma, diplopia, floaters, excessive tearing or photophobia. She has had no recent ear infections, drainage or pain.

She does have a history recent sinus infection. She denies loss of taste, no difficulty in chewing and no swallowing and tooth/ gum pain or bleeding.

Neck: No pain on the neck, no injury or history of disc disease

Chest/Lungs: No chest pain

Heart/Peripheral Vascular: SOB, S1 and S2 audible, no murmur, gallops, heaves, or thrills. PMI at 4-5th ICS, MCL.

Abdomen: Bowel sounds present in all four quadrants, No masses palpated.

No lesions observed

Genital/Rectal: no cervical motion tenderness, no adnexal masses.

Musculoskeletal: age-related atrophy; muscle strengths 5/5 all groups.

Neurological: Alert and oriented to person, place, and time. CN II-X is intact.

Skin: rashes on the right arm, no radiation of rash at this time, no itching, no acne,

 History of moles on left fingers

LAB/DIAGNOSTIC TESTS/EKG: No diagnostic studies were performed.

The clinical appearance is sufficient for a distinctive diagnosis.

Soap note nursing example

The PICOT question format is a consistent "formula" for developing answerable, researchable questions. When you write a good one, it makes the rest of the process of finding and evaluating evidence much more straightforward.
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