SOAP Note Example
Nursing SOAP Note Example
Below is a complete SOAP note example for a registered nurse documenting a follow-up visit with a patient newly diagnosed with Type 2 diabetes mellitus. This example demonstrates thorough nursing assessment, vital signs documentation, focused physical exam findings, patient education with teach-back, medication reconciliation, and interdisciplinary care coordination.
Complete Nursing Note
SUBJECTIVE:
Patient is a 52-year-old female presenting for a follow-up nursing visit, 3 weeks after initial diagnosis of Type 2 diabetes mellitus (diagnosed by PCP Dr. Nakamura on 02/07/2026). Reports feeling "overwhelmed but trying to do the right things" with her new self-management routine. States she has been checking fasting blood glucose daily as instructed and provides her glucose log for review — readings over the past 7 days ranged from 155 to 210 mg/dL, with an average of 178 mg/dL. Reports increased thirst and urinary frequency persisting since diagnosis, waking 2-3 times nightly to urinate, which is disrupting her sleep. Denies any episodes of hypoglycemia — no shakiness, diaphoresis, confusion, or palpitations. Reports intermittent tingling in both feet, predominantly at night, onset approximately 2 months ago before diabetes was diagnosed. Describes dietary changes since diagnosis: "I completely cut out regular soda and sweet tea, and I'm trying to eat less bread and pasta, but I'm not always sure what to replace them with." Has not started a regular exercise routine, citing fatigue and uncertainty about what types of activity are safe given her new diagnosis. Denies blurred vision, chest pain, shortness of breath, dizziness, or wounds that are slow to heal. Admits she missed 2-3 doses of her evening metformin over the past week, explaining that she remembers the morning dose because she takes it with breakfast but forgets the evening dose because her dinner schedule is inconsistent. Current medications: metformin 500 mg twice daily (with meals), lisinopril 10 mg daily (morning), atorvastatin 20 mg daily (bedtime). Allergies: sulfa drugs (rash). No over-the-counter supplements, herbal medications, or vitamins reported. Social history: non-smoker, occasional alcohol use (1-2 glasses of wine per week, no change since diagnosis), employed full-time as a school administrator, lives with spouse who is supportive of dietary changes. Family history: mother with Type 2 diabetes (managed with insulin), father deceased from myocardial infarction at age 60.
OBJECTIVE:
Vital signs: blood pressure 138/86 mmHg (left arm, seated 5 minutes, manual cuff — repeated at end of visit: 136/84 mmHg), heart rate 78 bpm regular, respiratory rate 16 breaths per minute, temperature 98.4 degrees Fahrenheit oral, SpO2 98% on room air. Anthropometrics: weight 198 lbs (89.8 kg), height 5 feet 5 inches (165.1 cm), BMI 32.9 (obese class I). Weight change: +1 lb from initial visit 3 weeks ago. General appearance: alert, oriented to person, place, time, and situation; cooperative; appears mildly anxious when discussing diabetes management, asking multiple questions about "doing this right." Skin assessment: warm, dry, intact throughout. No skin breakdown, rashes, lesions, or areas of discoloration noted on bilateral upper and lower extremities. Injection sites not applicable (not currently on insulin). Focused foot exam: bilateral pedal pulses palpable — dorsalis pedis 2+ bilaterally, posterior tibial 2+ bilaterally. Skin on feet intact, warm, no calluses, fissures, blisters, or ulcerations. No interdigital maceration or fungal infection noted. Nails intact, appropriately trimmed, no onychomycosis. Hair growth present on dorsal feet and toes bilaterally. Capillary refill less than 3 seconds all toes bilaterally. Semmes-Weinstein monofilament testing (10 g): left foot — sensation detected at 4 of 10 standard sites (absent at 1st metatarsal head, 3rd metatarsal head, 5th metatarsal head, great toe plantar surface, heel, and medial arch); right foot — sensation detected at 5 of 10 standard sites (absent at 1st metatarsal head, 5th metatarsal head, great toe plantar surface, heel, and lateral arch). Diminished protective sensation bilateral feet. Cardiovascular: S1 and S2 regular rate and rhythm, no murmurs, gallops, or rubs auscultated. No jugular venous distention. No peripheral edema bilateral lower extremities. Respiratory: lungs clear to auscultation in all fields bilaterally, no wheezes, crackles, or rhonchi. Abdomen: soft, non-tender, non-distended, normoactive bowel sounds in all 4 quadrants. No hepatomegaly. Laboratory results reviewed (drawn 2 days ago, ordered by Dr. Nakamura): HbA1c 8.4%, fasting glucose 188 mg/dL, BUN 18 mg/dL, creatinine 0.9 mg/dL, eGFR 78 mL/min/1.73 m2, sodium 140 mEq/L, potassium 4.2 mEq/L, total cholesterol 212 mg/dL, LDL 128 mg/dL, HDL 42 mg/dL, triglycerides 210 mg/dL, ALT 28 U/L, AST 24 U/L. Urinalysis: specific gravity 1.020, pH 6.0, glucose trace positive, protein negative, ketones negative, blood negative, leukocyte esterase negative. Urine microalbumin-to-creatinine ratio: 22 mg/g (normal less than 30). Medication reconciliation completed: metformin 500 mg BID — confirmed taking morning dose consistently with breakfast, evening dose missed 2-3 times in the past week as reported; lisinopril 10 mg daily — compliant, taking every morning; atorvastatin 20 mg daily — compliant, taking at bedtime. No new OTC medications, supplements, or herbal products.
ASSESSMENT:
Patient is a 52-year-old female with newly diagnosed Type 2 diabetes mellitus (3 weeks since diagnosis) with suboptimal glycemic control. HbA1c of 8.4% and fasting glucose readings of 155-210 mg/dL are above ADA targets (HbA1c less than 7%, fasting glucose 80-130 mg/dL). Contributing factors to current glycemic status include incomplete medication adherence (missed evening metformin doses due to inconsistent dinner schedule), limited nutritional knowledge specifically regarding carbohydrate identification and meal substitution, and absence of physical activity. Patient has made meaningful initial lifestyle changes (eliminating sugar-sweetened beverages) but requires structured nutritional counseling to build on this foundation. Monofilament testing reveals diminished protective sensation bilaterally (left 4/10, right 5/10), which is concerning for early diabetic peripheral neuropathy — this finding is consistent with the patient's report of bilateral foot tingling for 2 months and predates the formal diabetes diagnosis, suggesting the hyperglycemia was present for a longer period before detection. This requires urgent podiatry referral and further neurological evaluation. Blood pressure readings of 138/86 and 136/84 are above the ADA-recommended target of less than 130/80 mmHg for patients with diabetes, despite current lisinopril 10 mg daily — provider should be notified to consider dose titration. Lipid panel shows LDL of 128 mg/dL (ADA target for diabetic patients less than 100 mg/dL) and triglycerides of 210 mg/dL (target less than 150 mg/dL) — atorvastatin dose may need adjustment per provider evaluation. Renal function is currently preserved (eGFR 78, urine microalbumin-to-creatinine ratio 22 — within normal range) but warrants annual monitoring. Patient is engaged, motivated, and asking appropriate questions, which supports a positive prognosis for self-management skill development with adequate education and support.
PLAN:
Nursing interventions completed this visit: (1) Diabetes self-management education — reviewed blood glucose targets per ADA guidelines (fasting 80-130 mg/dL, pre-meal less than 130 mg/dL, 1-2 hour post-meal less than 180 mg/dL, HbA1c goal less than 7%); reviewed signs and symptoms of hypoglycemia (shakiness, sweating, confusion, rapid heartbeat, hunger) and hyperglycemia (increased thirst, frequent urination, blurred vision, fatigue) with printed handout provided; patient verbalized understanding and successfully completed teach-back for both hypo- and hyperglycemia recognition; reviewed when to seek emergency care (blood glucose greater than 400 mg/dL, symptoms of diabetic ketoacidosis including nausea/vomiting with fruity breath, or blood glucose less than 54 mg/dL unresponsive to treatment). (2) Medication adherence counseling — discussed specific strategies for the evening metformin dose: patient selected setting a recurring phone alarm for 6:30 PM paired with a note on the refrigerator, and using a weekly pill organizer prepared every Sunday; alarm was set on patient's phone during the visit; reinforced the importance of taking metformin with food to reduce gastrointestinal side effects and to support consistent glucose control. (3) Foot care education — demonstrated daily foot inspection technique using a hand mirror for soles; reviewed the importance of wearing supportive, closed-toe shoes at all times including indoors; instructed patient to avoid walking barefoot, to check bath water temperature with elbow before entering, and to moisturize feet daily but not between the toes; patient performed return demonstration of visual foot inspection satisfactorily; provided written foot care instruction sheet. (4) Nutrition education — reviewed the ADA plate method for meal planning (half the plate non-starchy vegetables, one quarter lean protein, one quarter whole grains or starchy foods); provided printed meal planning guide with a sample 3-day menu and a list of common carbohydrate-containing foods with serving sizes; discussed that eliminating soda was an excellent first step and identified next targets for carbohydrate reduction. (5) Physical activity counseling — discussed ADA recommendation of 150 minutes per week of moderate-intensity aerobic activity; recommended starting with 10-minute walks after meals to help with post-meal glucose levels, gradually increasing to 30 minutes; reassured patient that walking is safe and beneficial, no physician clearance needed for moderate walking. Referrals placed: registered dietitian for comprehensive medical nutrition therapy (MNT) — appointment scheduled for 03/10/2026; certified diabetes care and education specialist (CDCES) for formal diabetes self-management education and support (DSMES) program — enrolled in 4-session group class beginning 03/15/2026; podiatry for baseline neuropathy evaluation and comprehensive diabetic foot exam given abnormal monofilament findings — referral submitted, patient to expect scheduling call within 1 week. Notify Dr. Nakamura via EHR message regarding the following: blood pressure above ADA target on two readings (138/86 and 136/84) — recommend considering lisinopril titration from 10 mg to 20 mg; monofilament testing results indicating diminished protective sensation bilaterally — recommend consideration of nerve conduction velocity study and gabapentin or pregabalin if neuropathic symptoms are impacting sleep; lipid panel above ADA targets (LDL 128, triglycerides 210) — recommend considering atorvastatin dose increase from 20 mg to 40 mg; HbA1c 8.4% with ongoing fasting glucose readings 155-210 — recommend evaluating for metformin dose increase from 500 mg BID to 1000 mg BID once adherence to current dose is confirmed. Patient to continue daily fasting blood glucose monitoring and maintain written log. Follow-up nursing visit in 4 weeks — will reassess medication adherence and glucose log trends, recheck blood pressure, evaluate progress with dietary changes and physical activity initiation, re-assess foot sensation, and review experience with the DSMES program. Patient instructed to call the office if fasting blood glucose exceeds 300 mg/dL on two consecutive readings, if she experiences signs of hypoglycemia, if she notices any foot wounds, blisters, color changes, or increased numbness, or if she develops persistent nausea or vomiting.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Nursing SOAP notes should capture the patient's own account of how they are managing their condition at home, including specific self-monitoring data (glucose log with values), adherence challenges with honest detail about the pattern and reason (forgetting the evening dose due to inconsistent dinner schedule — not just 'non-compliant'), dietary changes attempted and where knowledge gaps remain, and any new or ongoing symptoms that could indicate complications (bilateral foot tingling suggesting neuropathy). Include the full medication list with doses, the allergy history, and relevant social and family history. The subjective section paints a complete picture of the patient as a person managing a chronic condition — this context is essential for tailoring education and anticipating barriers.
Objective
Document a complete set of vital signs with the method, position, and any repeats (blood pressure rechecked at end of visit to confirm an elevated reading). Calculate and record BMI. For diabetic patients, the focused foot exam is an essential component of nursing documentation — record pedal pulses, skin integrity, and monofilament results at each specific site tested (4/10 left, 5/10 right) rather than simply 'diminished.' Review and include relevant lab values with the date drawn and flag any results that are outside target ranges for a diabetic patient. Medication reconciliation must confirm every medication with dose, frequency, route, and actual adherence pattern — this is both a patient safety measure and a Joint Commission requirement. This thorough objective documentation supports the nursing assessment and ensures the provider team is alerted to issues requiring medical decision-making.
Assessment
The nursing assessment synthesizes subjective reports and objective findings into clinical conclusions. Identify the specific contributing factors to the current clinical picture (medication non-adherence, limited nutritional knowledge, no physical activity) because these are the problems your nursing interventions will address. Flag findings that require the provider's attention and specify what action you are recommending — this is not overstepping scope; it is the nurse functioning as a critical member of the care team. A nursing assessment differs from a medical assessment in its focus: it emphasizes the patient's response to their condition, their self-management capacity, their learning needs and readiness, and the barriers to achieving health outcomes. This section justifies the nursing visit and the time spent on education.
Plan
The nursing plan should document all education provided and specify the teaching method used (demonstration, teach-back, return demonstration, written materials) to prove that the patient received and understood the instruction — teach-back documentation is a Joint Commission and CMS quality standard. Detail the specific adherence strategies discussed and which ones the patient selected (phone alarm set during the visit, not just 'encouraged compliance'). List every referral placed with the specific reason and appointment date if available. Clearly delineate which clinical findings require the provider's attention and include your specific recommendation for each (lisinopril titration, neuropathy workup, statin adjustment, metformin dose increase). Include measurable parameters for the follow-up visit (glucose log review, BP recheck, foot re-assessment) and explicit return precautions with specific thresholds so the patient knows exactly when to call.
Generate Nursing Notes with AI
Stop writing notes from scratch. Wellistic AI generates professional SOAP notes from your brief session summary.
Start Generating Notes in 30 Seconds
Join thousands of wellness practitioners saving hours on documentation every week.