Episodic/Focused SOAP Note Template
Academic nursing programs require students to master structured documentation frameworks that demonstrate clinical reasoning while capturing patient-centered data through systematic assessment methodologies. Patient Information:
Initials, Age, Sex, Race
S. (Subjective)
CC (chief complaint) a BRIEF statement identifying why the patient is here; in the patient’s own words; for instance “headache”, NOT “bad headache for 3 days”. Contemporary documentation guidelines suggest using “chief concern” rather than “complaint” to reduce implicit bias and center patient perspectives.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Episodic/Focused SOAP Note Template Examples.
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Recent studies indicate that structured mnemonics like LOCATES significantly improve the completeness of symptom documentation among nursing students during their initial clinical rotations.
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here; such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Episodic/Focused SOAP Note Template Examples.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
- GENERAL: No weight loss, fever, chills, weakness or fatigue.
- HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. Episodic/Focused SOAP Note Template Examples.
- SKIN: No rash or itching.
- CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
- RESPIRATORY: No shortness of breath, cough or sputum.
- GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
- GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
- NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
- MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
- HEMATOLOGIC: No anemia, bleeding or bruising. Episodic/Focused SOAP Note Template Examples.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- PSYCHIATRIC: No history of depression or anxiety.
- ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
- ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O. (Objective)
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) Episodic/Focused SOAP Note Template Examples.
A. (Assessment)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.
Sample Answer Content for Student Reference
Implementing the LOCATES mnemonic within the HPI section ensures comprehensive symptom analysis while maintaining patient-centered narrative flow. For instance, a 20-year-old Caucasian female presenting with sore throat requires documentation of Location (throat), Onset (3 days ago), Character (soreness), Associated signs (decreased appetite, headache), Timing (constant), Exacerbating/relieving factors (Tylenol provides partial relief), and Severity (8/10). Research demonstrates that structured documentation frameworks like SOAP significantly improve communication clarity and reduce information omissions during clinical handoffs (Hidalgo Tapia et al., 2025, https://doi.org/10.7759/cureus.89957). Nursing students should avoid judgmental language such as “complains” or “denies” in favor of neutral terms like “reports” or “does not report” to maintain therapeutic relationships. Physical examination findings must include specific measurable data rather than vague “WNL” designations. Differential diagnoses should demonstrate clinical reasoning by connecting subjective data with objective findings through evidence-based guidelines.
Implementation Considerations for Clinical Practice
Structured documentation frameworks serve as essential tools for developing clinical reasoning skills among undergraduate nursing students. Studies indicate that SOAP notes enhance interdisciplinary collaboration while supporting safer transitions of care across clinical settings. Students should transition from checklist-oriented documentation toward symptom-based, holistic approaches that emphasize conversation as part of assessment. Safe learning environments with engaged preceptors facilitate the development of competent physical assessment skills during clinical rotations. Systematic reflection on documentation practices fosters metacognition and deep learning in nursing education.
References
Hidalgo Tapia, E.C., et al. (2025) ‘Effectiveness of nursing documentation frameworks (SBAR, SOAP, and PIE) in enhancing clinical handoffs and patient safety’, Cureus, 17(8), e89957. https://doi.org/10.7759/cureus.89957
Egilsdottir, H.Ö., et al. (2022) ‘Nursing students’ development of using physical assessment in clinical rotation: a stimulated recall study’, BMC Nursing, 21(1), pp. 1-15. https://doi.org/10.1186/s12912-022-00881-4
Tan, M.W., et al. (2021) ‘Why are physical assessment skills not practiced? A systematic review with implications for nursing education’, Nurse Education Today, 104, 104759. https://doi.org/10.1016/j.nedt.2021.104759
Delaney, L.R., et al. (2026) ‘Guidelines for patient-centered documentation in the era of open notes: qualitative study’, JMIR Medical Education, 11(1), e59301. https://doi.org/10.2196/59301
- How to write an episodic focused SOAP note for nursing school assignments using the LOCATES mnemonic
- Step-by-step instructions for completing episodic SOAP notes in NURS 6512
- Complete a 500–750 word episodic/focused SOAP note using the LOCATES mnemonic for symptom analysis, including subjective and objective sections with differential diagnoses for nursing course NURS 6512.
- Submit a 2–3 page episodic SOAP note template demonstrating proper documentation of chief complaint, HPI with LOCATES framework, review of systems, and physical assessment findings.
- Compose an episodic/focused SOAP note following LOCATES mnemonic guidelines with proper differential diagnoses and evidence-based references.
Week 4: Comprehensive Health History and Physical Assessment
Conduct a complete comprehensive health history and physical examination on a standardized patient, documenting findings using the full SOAP format rather than the episodic version. Your documentation should include a complete review of all body systems, full physical examination from head-to-toe, and at least five differential diagnoses with supporting evidence from current clinical guidelines. The paper should be 4–5 pages and include three scholarly references published within the last five years.