Walden SOAP Note Format for NP Students: Section by Section
A Walden SOAP note is the standard way nurse practitioner students document a patient encounter in NURS 6512 and the NRNP clinical courses. SOAP stands for subjective, objective, assessment and plan, and the format trains the clinical reasoning that turns a patient's story and examination into a diagnosis and a plan of care. Walden courses supply their own templates, which take precedence, but the logic is the same across them. This guide walks through each section, shows what faculty look for and lists the mistakes that cost Walden NP students points.
Walden SOAP note subjective section
The subjective section records what the patient tells you. It usually begins with the chief complaint in the patient's own words, followed by the history of present illness, often organized with a mnemonic such as OLDCARTS: onset, location, duration, character, aggravating factors, relieving factors, timing and severity.
It continues with the past medical history, surgical history, medications with doses, allergies with reactions, family history, social history and a review of systems relevant to the complaint.
The review of systems records what the patient reports, not what you find on examination. A common mistake is placing examination findings here.
Pertinent negatives matter. Noting that a patient with chest pain denies shortness of breath or diaphoresis is as important as noting what they do report.
Keep the language objective and specific. Patient reports sharp, intermittent left-sided chest pain for two days is better than patient has chest pain.
For psychiatric notes, the subjective section also covers psychiatric history, substance use, trauma history and current stressors, and for pediatric notes it includes developmental and immunization history.
Walden SOAP note objective section
The objective section records what you observe and measure: vital signs, general appearance and the physical examination, organized by system, plus any test results available at the visit.
For a focused note, the examination concentrates on the systems relevant to the complaint, with enough related systems to support or rule out the differentials. A focused respiratory note includes the chest, but often also the heart, ears, nose and throat.
Findings are described precisely: crackles at the right lung base, not abnormal lung sounds; tympanic membrane erythematous and bulging, not ear looks infected.
Normal findings are documented too, because they help rule out alternative diagnoses.
Avoid interpretation here. The objective section reports what is found; what it means belongs in the assessment.
Psychiatric notes replace much of the physical examination with a mental status examination, describing appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight and judgment.
Walden SOAP note assessment and differential diagnoses
The assessment brings the subjective and objective findings together into a diagnosis. Walden courses usually ask for a primary diagnosis and a ranked list of differential diagnoses, often three to five.
Each differential needs a justification: the findings that support it and those that argue against it. Simply listing diagnoses without reasoning earns little.
Ranking matters. The most likely diagnosis comes first, and dangerous diagnoses that must be ruled out are noted even if less likely, such as pulmonary embolism in a patient with chest pain.
Citing evidence strengthens the assessment. Clinical guidelines and diagnostic criteria, such as the Centor criteria for sore throat or the DSM-5-TR for psychiatric diagnoses, support the reasoning.
ICD-10 codes are sometimes required. If your template asks for them, include the code alongside each diagnosis.
For comprehensive notes, the assessment may list several active problems, each with its own reasoning, rather than a single primary diagnosis.
Walden SOAP note plan section
The plan describes what happens next, usually under several headings: diagnostic tests, medications, non-pharmacologic treatment, patient education, referrals and follow-up.
Medications include the drug, dose, route, frequency and duration, adjusted for the patient's age, kidney and liver function, pregnancy status and other medications. A plan that names a drug without a dose is incomplete.
The plan should follow current guidelines, cited in the note, such as the ADA Standards of Care, GINA for asthma or the ACC/AHA guidance for hypertension.
Patient education is specific: what the patient should do, what warning signs should prompt a return and how the medication should be taken.
Follow-up states when and why the patient should be seen again, and health promotion items, such as screening and vaccinations, are added where appropriate.
For chronic conditions, the plan also notes how the condition is controlled now, what targets apply, such as a blood pressure or hemoglobin A1c goal, and how the treatment will change if those targets are not met.
Common Walden SOAP note mistakes
Mixing subjective and objective information is the most common mistake. What the patient says goes in S; what you find goes in O.
Unranked or unsupported differentials are next. Each differential needs reasoning, and the list should be ordered by likelihood and danger.
Incomplete prescriptions, missing doses, routes or durations, cost points, as do plans that ignore interactions or special populations.
Missing follow-up and education are frequent losses, because faculty treat them as part of safe practice.
Finally, outdated guidelines cost credibility. Clinical guidance changes, and notes should cite the current version.
Overlong notes cost points too. A focused note should stay focused; including a full head-to-toe examination for a sprained ankle suggests the writer is not distinguishing relevant from irrelevant findings.
Abbreviations can cost points as well. Standard clinical abbreviations are usually fine, but unusual ones, or any that patient safety bodies have flagged as easy to misread, such as U for units, should be written out in full.
Practicing the Walden SOAP note format
Use the course template every time. Walden templates may add elements, such as reflection or coding, and following them exactly avoids easy losses.
Write notes from real encounters during practicum, with all identifying information removed. Practice with real patients builds speed and accuracy.
Build a list of the guidelines you use most, so citations are quick to find.
Review faculty feedback on each note and fix recurring issues in the next one.
For students who need help, nurse practitioners on this desk write SOAP notes and case studies from de-identified details, following the course template, while practicum hours, logs and recorded assessments stay with the student.
Compare your notes with model examples from your course resources when they are provided, paying attention to how experienced clinicians phrase findings and justify differentials.
Time yourself occasionally. In clinical practice a focused note is written in minutes, and practicing a concise version builds a habit that serves you well after graduation.
Walden SOAP notes: questions answered
What does SOAP stand for?
Subjective, objective, assessment and plan.
How many differential diagnoses should a Walden SOAP note have?
Often three to five, ranked and justified, but follow your course's template. Dangerous diagnoses that must be ruled out are listed even when less likely.
Where do review of systems findings go?
In the subjective section, because they are what the patient reports.
Do Walden SOAP notes need citations?
Usually yes, especially for diagnostic criteria and treatment guidelines, in APA 7. Cite the current edition of each guideline.
Can I use a real patient?
Yes, with all identifying information removed, if your course allows practicum-based notes. Names, dates of birth and record numbers must never appear.
Can someone help write my SOAP notes?
Yes. Nurse practitioners can write them from de-identified details in your course's format.