The OBJECTIVE section of a SOAP note plays is a critical component as it helps assess, evaluate and document the correct and accurate data on a patient a PMHNP or APRN. This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things.
SOAP Notes objective examples 1
| Objective | Vitals: Height: 5’10” Weight: 170 BMI: 24.4 BP: 128/24 HR: 78 RR: 16 T: 98.6F Labs: Unavailable at this time. Mental Status Exam: Observation: Appearance: Clothing soiled, but appropriately dressed for age and season Speech: Spontaneous, appropriate rate, appropriate tone, and low volume without pressured speech, with some problems expressing self Eye contact: Intermittent Motor Activity: Normal Affect: Full, even, and congruent with mood Mood: “Good” Cognition: Orientation: Alert, oriented to person, place, time, and situation Memory: Intact Attention/Concentration: Limited Perception: Reports auditory and visual hallucinations Thought Content: Suicidality: None Homicidality: None Delusions: None Thought Process: Disorganized with a flight of ideas Behavior: Cooperative and conversant, appears without acute distress Insight: Poor Judgment: Poor Schizophrenia Assessment Tool: PANSS positive scale score: 24 PANSS negative scale score: 12 PANSS general psychopathology scale score: 33 Total PANSS score= 69 Alcohol Use Assessment Tool: AUDIT score= 36 and Cocaine Use Assessment Tool: DAST-10 score= 8 Physical Exam: Not applicable |
This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things. how to write soap notes
SOAP Notes objective example 2
Objective Vital Signs: Stable
Temp:
BP:
HR:
R:
O2:
Pain:
Ht:
Wt:
BMI:
BMI Range:
LABS:
Lab findings WNL
Tox screen: Negative
Alcohol: Negative
HCG: N/A
Physical Exam:
MSE:
Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4.
Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.
Presents with appropriate eye contact, euthymic affect – full, even, congruent with reported mood of “x”. Speech: spontaneous, normal rate, appropriate volume/tone with no problems expressing self.
TC: no abnormal content elicited, denies suicidal ideation, and denies homicidal ideation. Process appears linear, coherent, and goal-directed. (SOAP notes objective examples)
Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge.
The judgment appears fair. Insight appears fair
The patient is able to articulate needs, and is motivated for compliance and adherence to a medication regimen. The patient is willing and able to participate in treatment, disposition, and discharge planning.
This is where the “facts” are located.
Vitals,
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, and test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things.
SOAP Notes objective example 3
| Objective | Vital Signs: BP 151/97, HR 90, Temp 97.5, RR 19, O2 97% Lab tests results CBC: currently unavailable. TSH- 1.9mU/L BUN levels- 12 mg/dL Serum creatinine levels 0.64mg/dL Physical Exam: None Contributory. MSE: Appearance: Well groomed, dressed for the occasion and appears the stated age Behavior: Composed, focused with intermittent eye contact Attitude: Cooperative, easy to establish a discussion Level of consciousness: Awake, Alert Orientation: A*4 Speech and Language: Soft clear, coherent Mood: context appropriate Affect: Mood congruent, moderately restricted Thought process/form: organized, goal directed, logical Thought content: Depressed, suicidal ideations Suicidality and homicidally: Has history of suicide attempts denies homicidal thoughts Insight and judgement: Insight considered to be good, judgement moderate Attention span: adequate to the needs of an outpatient program, age appropriate Memory: Both recent and remote deemed intact Intellectual functionality: Intellectually capable Relevant Screening Tools GAD-7: Was used to screen for generalized anxiety and her score was 13 –moderate anxiety Patient Health Questionnaire (PHQ-9) -12 moderate depression Columbia Suicide Severity Rating Scale (C- SSRS): Moderate risk Appearance: Good hygiene, neat appearance, looks stated age This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things. |
What to learn more about soap notes? You might find these interesting (SOAP notes objective examples)
- What is a SOAP Note? [Subjective, Objective, Assessment, and Plan Examples]
- SOAP NOTE SUBJECTIVE Examples [UPDATED]
- SOAP Notes Assessment Examples | Guide & Outline
- Clinical SOAP Note Depression (SOAP notes for mental health examples)
- Comprehensive SOAP Solved Sample
- SOAP Note Sample | Practical Guide & Outline | Updated
- 1 SOAP NOTE Plan Outline
- 2 SOAP NOTE Plan Examples 1
- 3 SOAP NOTE Plan Examples 2
- 4 SOAP NOTE Plan Examples 3
This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things.
This short guide includes 3 SOAP note objective examples you can use when writing. Alternatively, since most have to do these SOAP notes every other week, let our nursing writers do it for you this week as you do other important things.
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