SOAP Note: Nursing Diagnoses

Step 3: Complete the SOAPE note form below, making sure that you provide two nursing diagnoses (with all three parts) that you think would work for the problem you identified.

  • Note: You do not have to complete the form entirely in one sitting. The system will remember you and the information you entered. Simply click the Save & Close button at the bottom right corner of the form before you leave the page.

Patient’s Chief Complaint

2, Please log the Patient’s Past Health History here:

3, Please log the Patient’s Family Health History here:

4 Please log the Patient’s Social History here:

5, Please log the Patient’s Functional Assessment here:

6, Please log the Review of the Patient’s Systems (ROS) here:

7, Include vital signs (VS), lab data, general appearance, demeanor, and Physical Assessment findings.

Report the vital signs here:

8, Report the lab data here:

9, Report on the patient’s general appearance here:

10, Report on your physical assessment findings here:

11, Assessment (Nursing Diagnosis)

Issues to address for health teaching—include two different topics of importance for your patient.

These issues should be drawn from your health history and physical exam findings and/or from the patient’s stated concerns.

For each topic, list the issue, why you chose it, what components you would include in teaching, and what your expected client outcomes would be.

12, Plan

A Plan to match both of the stated Nursing Diagnoses—you need as many interventions as necessary. The “a,b,c” indicates that multiple interventions will be sought.

13, Evaluation

Evaluation of the stated plan stated for both Nursing Diagnoses— you need as many evaluations as necessary. The “a,b,c” indicates that multiple evaluations will be sought.

These evaluations must coordinate with the Plan.

14,

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