If you work in healthcare, you know that good communication is everything. What we write in a patient’s chart is a crucial part of that communication. It keeps the whole team on the same page and ensures safe, continuous care. One of the best and most common ways to write these notes is called “SOAPIE.” In this blog we will explain SOAPIE charting step-by-step. We will break down each letter. We will show you why each part matters. And we will give you tips to make your notes helpful for everyone. Whether you are a new nurse, a nursing student, or a seasoned pro needing a refresher, this guide is for you.
Let’s get started.
What is SOAPIE Charting?
SOAPIE stands for Subjective, Objective, Assessment, Plan, Intervention, and Evaluation. It is a structured format for writing progress notes in a patient’s medical record. Think of it as a clear, step-by-step recipe for documenting a patient’s story and your care.
Before methods like SOAPIE, notes could be messy and hard to follow. Important information could be missed. The SOAPIE format creates a standard. Everyone on the team knows where to look for specific details. This saves time and prevents errors. It is used by nurses, therapists, doctors, and many other healthcare providers.
Using SOAPIE is not just about filling in boxes. It is about critical thinking. It forces you to gather information (Subjective and Objective), analyze it (Assessment), and then describe your actions (Plan, Intervention) and their results (Evaluation). This logical flow mirrors the nursing process and good clinical reasoning.
Why is SOAPIE Charting So Important?
You might wonder why we need such a strict format. Can’t we just write what happened? The problem with simple storytelling is that details get lost. SOAPIE organizes thoughts and information. This is vital for several key reasons.
First, it ensures patient safety. A clear note tells the next nurse or doctor exactly what has been done and what to watch for. If a note is confusing, a medication could be given twice, or a worsening symptom could be missed. Good documentation is a major part of safe care.
Second, it supports team communication. The physical therapist, the dietitian, and the surgeon all read the same chart. SOAPIE gives them a familiar map to find the information they need quickly. They don’t have to read a long paragraph to find the patient’s latest blood pressure or pain level.
It serves as a legal record. The medical chart is a legal document. If there is ever a question about the care provided, the court will look at your notes. Clear, thorough, and timely SOAPIE notes are your best professional defense. They show exactly what you saw, thought, did, and how the patient responded.
Breaking Down the SOAPIE: Letter by Letter
Now, let’s explore each part of the SOAPIE acronym. We will explain what belongs in each section and provide simple examples.
S: Subjective Information
The “S” stands for Subjective. This is information that comes from the patient, their family, or their friends. It is what the patient says they are feeling or experiencing. You cannot measure this information with a machine. It is based on their personal report.
What goes here? Start with the patient’s chief complaint in their own words. For example: “My stomach hurts really bad,” or “I feel short of breath.” Then, include other statements about their symptoms. Describe the pain (sharp, dull, throbbing), its location, and what makes it better or worse. Also include the patient’s feelings, concerns, and relevant past history they tell you.
Example: Pt states, “I have a crushing pain in my chest that goes to my left arm. It started about 30 minutes ago. I feel dizzy and sick to my stomach.” Pt reports a history of high blood pressure. Pt says he is “very scared.”
Remember: Always use quotation marks for direct quotes. For other subjective info, use phrases like “Pt reports…”, “Pt describes…”, or “Family states…”. This makes it clear this is not a measured fact, but the patient’s perspective.
O: Objective Information
The “O” stands for Objective. This is the opposite of subjective. Objective data is what you can see, hear, feel, smell, or measure. It is factual and verifiable. Any other team member should be able to get the same result.
This section is all about hard facts. Include vital signs: blood pressure, heart rate, temperature, breathing rate, and oxygen level. Write down physical exam findings: “Skin is warm and dry,” “Lungs are clear to auscultation,” “Abdomen is soft and non-tender.” Put in lab results, imaging reports, and intake/output numbers.
Example: *BP 178/92, HR 118 and irregular, RR 24, SpO2 94% on room air. Skin is pale and diaphoretic (sweaty). ECG shows ST elevation in leads V2-V4. Breath sounds clear bilaterally.*
Be specific and accurate. Instead of “high blood pressure,” write “BP 178/92.” Instead of “fever,” write “Temp 101.4°F.” This removes any guesswork for the reader. The objective section should paint a clear, measurable picture of the patient’s condition at that moment.
A: Assessment
The “A” is your Assessment. This is where you, the healthcare professional, put the pieces together. You analyze the subjective and objective information. You state your professional judgment about what is going on with the patient.
Think of this as the “so what?” section. Based on the data, what is your assessment of the problem? For a nurse, this often includes nursing diagnoses. These are standardized statements about a patient’s response to a health problem. For other providers, it may be a medical diagnosis or a clinical impression.
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Example (Nursing): 1) Acute pain related to myocardial ischemia as evidenced by patient’s report of crushing chest pain and diaphoresis. 2) Anxiety related to threat of death as evidenced by patient’s statement “I’m very scared” and elevated HR. 3) Decreased cardiac output related to dysrhythmia as evidenced by irregular HR and hypotension.
Your assessment should directly link to the data in S and O. It shows you are not just collecting information, but thinking critically about it. This is the bridge between identifying problems and planning care.
P: Plan
The “P” stands for Plan. Now that you have assessed the situation, what are you going to do about it? The plan outlines the goals and the steps you intend to take to address the problems you identified in your Assessment.
The plan should be specific and realistic. It includes both immediate next steps and longer-term goals. What will you monitor? What tests or consults need to be ordered? What patient education will you provide? What is the desired outcome for the patient?
Example: *1) Relieve chest pain and improve cardiac output. 2) Reduce patient’s anxiety. 3) Monitor for complications of acute MI. Plan: Administer prescribed nitroglycerin and morphine. Start O2 at 2L via nasal cannula. Obtain 12-lead ECG. Notify cardiology team for urgent consult. Remain with patient to provide reassurance and explain procedures. Continue to monitor vital signs and rhythm every 15 minutes.*
A good plan is a roadmap for care. It guides your own actions and informs the rest of the team about the intended direction. Each part of the plan should connect back to an item in your Assessment.
I: Interventions
The “I” is for Interventions. This section is sometimes combined with the Plan. But when separated, it is where you document the care you actually performed. The Plan says what you will do; Interventions document what you did do.
This is a straightforward record of your actions. Be precise. Include times, doses, routes, and your patient’s response to the intervention in the moment.
Example: *0925: Administered nitroglycerin 0.4 mg sublingual as prescribed. 0930: Patient reports pain decreased from 8/10 to 6/10. Started O2 at 2L per nasal cannula. SpO2 increased to 98%. 0935: Obtained 12-lead ECG and placed at bedside. 0940: Notified Dr. Smith of ECG findings. New orders received. 0945: Administered morphine 2mg IV as per new order. Provided calm reassurance and explained plan of care to patient.*
Documenting interventions accurately is critical for continuity. The next caregiver needs to know exactly what was done and when. It also fulfills the legal requirement to record all care provided.
E: Evaluation
Finally, the “E” is Evaluation. This is where you close the loop. You assess the patient’s response to your interventions. Did they work? Is the patient better, worse, or the same? This shows the effectiveness of your care and determines the next steps.
Your evaluation should refer back to the problems in your Assessment and the goals in your Plan. What changed after your interventions? Use objective data and the patient’s subjective report.
Example: *0955: Reassessed pain. Pt states pain is now 2/10 and describes it as “a dull ache.” BP 150/84, HR 98 and regular, RR 18, SpO2 99% on O2. Skin is less diaphoretic. Pt states, “I feel a lot better and less scared.” Plan to continue monitoring per protocol and reassess in 30 minutes.*
Evaluation is not just a one-time thing. It is an ongoing process. Each evaluation leads to a new Assessment, which may create a new Plan, leading to new Interventions and another Evaluation. This cycle is the heart of dynamic, patient-centered care.
SOAPIE Note Example
Let’s see a full SOAPIE note for a different patient scenario.
Situation: Post-operative patient on the surgical floor, day 1 after an appendectomy.
SOAPIE Note:
S: Pt grimacing and holding abdomen. States, “The pain is really sharp where they cut me, especially when I try to move or cough.” Rates pain as 8/10. Says, “I’m afraid to move because it hurts too much.”
O: 1400: T 98.8°F, BP 138/88, HR 102, RR 22. Incision site on RLQ: no redness, minimal serous drainage on dressing, edges closed. Breath sounds: diminished in bilateral bases. Has not used incentive spirometer in 2 hours. Refused to ambulate this AM due to pain.
A: 1) Acute pain related to surgical incision as evidenced by pain rating of 8/10 and guarding. 2) Risk for impaired gas exchange and pneumonia related to shallow breathing and refusal to ambulate/cough due to pain.
P: 1) Reduce pain to a manageable level (goal <4/10) to allow for movement. 2) Encourage deep breathing and ambulation to prevent complications. Plan: Medicate for pain as ordered. Re-educate on importance of spirometer and walking. Assist with first ambulation after medication.
I: 1410: Administered oxycodone 5mg PO as prescribed. 1425: Revisited patient. Provided education on link between pain control, deep breathing, walking, and preventing lung problems. 1430: Assisted patient to sit on edge of bed, then ambulate 10 feet to chair. Patient used incentive spirometer, achieved 1000 mL volume.
E: 1445: Pt reports pain now 3/10. States, “That’s much better. I can take a deep breath now.” Using spirometer easily. BP 126/80, HR 88, RR 16. Breath sounds slightly clearer. Will continue to encourage activity and monitor pain.
Common Mistakes to Avoid in SOAPIE Charting
Even with a good structure, errors can happen. Here are some common pitfalls and how to avoid them.
1. Mixing Subjective and Objective: Putting the patient’s quote in the Objective section, or putting a vital sign in Subjective, confuses the reader. Keep them strictly separate. Remember: S = they say, O = you see.
2. Being Vague or Using Clichés: Notes like “patient had a good day” or “status unchanged” are not helpful. What does “good” mean? What is “status”? Always be specific. Instead, write: “Pt ambulated 100 ft in hall without shortness of breath. Appetite good, ate 75% of lunch.”
3. Writing an Opinion as Fact in Assessment: Your Assessment should be a professional conclusion based on data. Avoid biases or assumptions not supported by S and O. Do not write “Pt is drug-seeking.” Instead, document the behavior objectively in O/S: “Pt requests pain medication every 2 hours on the clock” and then assess “Ineffective management of chronic pain.”
4. Forgetting the Evaluation: The note should not just stop after you list what you did. The Evaluation is crucial. It shows whether your care was effective and what should happen next. Always complete the cycle.
5. Late or Incomplete Charting: Charting hours later from memory is dangerous and illegal. Information can be forgotten or mixed up. Chart as close to real-time as possible, and make sure every section is complete for that shift or encounter.
Tips for Excellent SOAPIE Notes
Here are some final tips to make your SOAPIE notes stand out as clear, professional, and valuable.
- Be Concise and Relevant: Stick to the point. Include information that affects care. The patient’s love for baseball might be nice, but unless it’s part of their motivation or therapy, it may not belong in a SOAPIE note.
- Use Standard Terminology: Use accepted medical abbreviations and nursing diagnosis language. This promotes clarity. But avoid obscure abbreviations that others might not know.
- Stay Patient-Centered: Remember, the story is about the patient. Use their words in the Subjective section. Tailor your Assessment and Plan to their specific needs and goals.
- Think Legally: Write every note as if it will be read in a courtroom. Be factual, non-judgmental, and accurate. If an error is made, follow your facility’s protocol for correction (usually a single line through the error, write “error,” date, and initial).
- Review and Reflect: Use the SOAPIE process not just as documentation, but as a thinking tool. It helps you structure your clinical reasoning, making you a more effective and thoughtful healthcare provider.
The Bottom Line
SOAPIE charting is much more than a documentation task. It is the backbone of clear communication, safe patient care, and professional accountability. By mastering the simple structure—Subjective, Objective, Assessment, Plan, Intervention, Evaluation—you ensure that every patient’s story is told completely and accurately.
This format guides your thinking, informs your team, and protects you and your patient. It turns a routine note into a powerful tool for healing. So, the next time you sit down to document, remember the SOAPIE recipe. Take it step-by-step. Be clear, be thorough, and be professional. Your patients and your colleagues will benefit from your excellent communication.
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Dr. Connor Yost is an Internal Medicine resident at Creighton University School of Medicine in Arizona and an emerging leader in clinical innovation. He currently serves as Chief Medical Officer at Skriber, where he helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Dr. Yost also works as a Strategic Advisor at Doc2Doc, lending his expertise to initiatives that improve financial wellness for physicians and trainees.
His professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare. Dr. Yost is committed to building systems that allow clinicians to spend more time with patients and less on administrative tasks. Outside of medicine, he enjoys photography, entrepreneurship, and family life.
