SOAP Notes in Primary Care: A Guide for NP Students (NRNP-6531) with Case-Based Documentation

As a Nurse Practitioner (NP) student in primary care, effective documentation is critical for ensuring continuity of care, improving patient outcomes, and meeting legal and ethical standards. SOAP notes (Subjective, Objective, Assessment, and Plan) are the most common framework used in clinical practice to document patient encounters. In this guide, we will walk through the SOAP note structure with case-based examples, tailored to common conditions in primary care.

What is a SOAP Note?

SOAP is an acronym that stands for:

S = Subjective: The patient’s reported symptoms, feelings, and concerns.
O = Objective: The clinician’s observations, physical examination findings, and diagnostic test results.
A = Assessment: The diagnosis or clinical impression based on the subjective and objective findings.
P = Plan: The treatment plan, including interventions, medications, and follow-up recommendations.

Long Tail Keywords for SOAP Notes in Primary Care:

How to write SOAP notes for Nurse Practitioners
Primary care SOAP notes examples for NP students
Best practices for documenting SOAP notes in primary care

Case 1: Hypertension (HTN)

S (Subjective):

Chief Complaint: “I’ve been feeling tired and having headaches for the past few weeks. My blood pressure has been high according to my home monitor.”
History of Present Illness: A 55-year-old male presents with complaints of tiredness, headaches, and occasional dizziness. He reports that his home blood pressure readings have been consistently above 140/90 mm Hg. He has a family history of hypertension and is non-compliant with medication due to side effects.
Past Medical History: Hypertension, obesity (BMI = 32), no known drug allergies.
Medications: Occasionally takes lisinopril but stopped due to dizziness.
Social History: Smokes 10 cigarettes/day and has a sedentary lifestyle.

O (Objective):

Vital Signs: BP 150/95 mm Hg, HR 78 bpm, Respirations 16, Temperature 98.6°F, Weight 220 lbs.
Physical Examination:
- General: Overweight, in no acute distress.
- Cardiovascular: Regular rhythm, no murmurs.
- Neurological: Alert and oriented, no focal deficits.
- Respiratory: Clear lung fields, no wheezing.
Labs/Diagnostics:
- CBC: Normal.
- Basic Metabolic Panel: Normal electrolytes, slightly elevated creatinine.
- ECG: Normal sinus rhythm.

A (Assessment):

Diagnosis: Primary Hypertension, Stage 1 (based on elevated BP readings).
Differential Diagnosis: Secondary causes of hypertension are less likely given the patient’s history and normal lab results.
Patient’s Risk: High risk for cardiovascular events due to poor BP control, obesity, and smoking.

P (Plan):

Medications: Start Amlodipine 5 mg daily for BP management.
Lifestyle Modifications: Recommend weight loss, increased physical activity (at least 150 minutes of moderate exercise per week), and smoking cessation.
Follow-up: Recheck BP in 2 weeks, and refer for a nutrition consultation.
Patient Education: Discuss hypertension management, side effects of medications, and the importance of regular BP monitoring at home.
Referrals: Refer to smoking cessation program.

Case 2: Type 2 Diabetes Mellitus (T2DM)

S (Subjective):

Chief Complaint: “I’ve been feeling thirsty all the time, and I have to go to the bathroom frequently.”
History of Present Illness: A 60-year-old female presents with complaints of polydipsia, polyuria, and fatigue. She has been experiencing these symptoms for the past few months. The patient is concerned about her increasing weight and difficulty managing her blood sugar levels.
Past Medical History: Type 2 diabetes diagnosed 5 years ago, hyperlipidemia, hypertension.
Medications: Metformin 1000 mg twice daily, Simvastatin 20 mg daily.
Social History: Non-smoker, sedentary lifestyle, occasionally drinks alcohol.

O (Objective):

Vital Signs: BP 130/85 mm Hg, HR 76 bpm, Weight 180 lbs, Height 5’4″, BMI 31.0.
Physical Examination:
- General: Obese, alert, and oriented, but appears fatigued.
- Cardiovascular: Normal S1, S2, no murmurs.
- Neurological: No focal deficits, decreased sensation in feet.
- Skin: Dry skin, no rashes or wounds.
Labs/Diagnostics:
- Fasting Blood Glucose: 180 mg/dL.
- HbA1c: 8.2%.
- Lipid Panel: Elevated total cholesterol (210 mg/dL), normal HDL (50 mg/dL), elevated LDL (130 mg/dL).

A (Assessment):

Diagnosis: Uncontrolled Type 2 Diabetes Mellitus, HbA1c 8.2% (above goal of <7%).
Complications: Possible diabetic neuropathy (decreased sensation in feet).
Co-morbid Conditions: Hyperlipidemia, hypertension.

P (Plan):

Medications:
- Continue Metformin 1000 mg twice daily.
- Add Empagliflozin (Jardiance) 10 mg daily for better glucose control and weight loss benefits.
Lifestyle Modifications:
- Dietary changes: Refer to a diabetes educator for meal planning and carbohydrate counting.
- Increase physical activity to at least 150 minutes of moderate exercise per week.
- Weight loss goal: Aim for 5-10% body weight reduction.
Follow-up: Schedule follow-up in 3 months for HbA1c recheck and review of symptoms.
Patient Education: Discuss blood glucose monitoring, recognizing signs of hyperglycemia and hypoglycemia, and foot care to prevent diabetic neuropathy complications.
Referrals: Refer to a podiatrist for a comprehensive foot exam and evaluation of neuropathy.

Case 3: Hyperlipidemia (High Cholesterol)

S (Subjective):

Chief Complaint: “I have a family history of heart disease, and my last blood work showed my cholesterol is high.”
History of Present Illness: A 50-year-old male presents for a routine check-up. He has a family history of coronary artery disease and is concerned about his elevated cholesterol levels.
Past Medical History: Hyperlipidemia, hypertension, no history of cardiovascular events.
Medications: None.
Social History: Non-smoker, drinks alcohol socially, sedentary lifestyle.

O (Objective):

Vital Signs: BP 135/85 mm Hg, HR 72 bpm, Weight 220 lbs.
Physical Examination:
- General: Overweight, in no acute distress.
- Cardiovascular: Normal S1, S2, no murmurs.
- Neurological: Normal sensation and strength.
Labs/Diagnostics:
- Lipid Profile:
  - Total Cholesterol: 240 mg/dL (elevated)
  - LDL: 160 mg/dL (elevated)
  - HDL: 35 mg/dL (low)
  - Triglycerides: 200 mg/dL (borderline high)

A (Assessment):

Diagnosis: Hyperlipidemia, with elevated LDL and low HDL. Risk factor for cardiovascular disease.
Risk Stratification: Moderate risk for heart disease based on lipid profile and family history.

P (Plan):

Medications:
- Start Atorvastatin 20 mg daily to reduce LDL cholesterol.
Lifestyle Modifications:
- Recommend a heart-healthy diet (low in saturated fats and cholesterol, high in fiber).
- Increase physical activity (recommend 30 minutes of moderate exercise 5 days per week).
- Weight loss: Aim for 5-10% reduction in body weight.
Follow-up: Recheck lipid profile in 3 months to assess response to therapy.
Patient Education: Discuss lifestyle changes and the role of statins in reducing cardiovascular risk.

Conclusion: SOAP Notes for Primary Care

SOAP notes are an essential documentation tool for Nurse Practitioners in primary care settings. They provide a structured approach to record patient encounters, ensuring continuity of care, improved patient outcomes, and legal compliance. By using the SOAP note format, NP students can clearly document subjective patient concerns, objective findings, clinical assessments, and comprehensive care plans for effective management of chronic conditions.

Using case-based documentation in SOAP format not only helps in better decision-making but also provides a detailed record for ongoing patient care.