A SOAPIE note is a nursing progress note with six sections: Subjective, Objective, Assessment, Plan, Intervention, and Evaluation. It’s the SOAP note plus two letters. Intervention is what you did. Evaluation is how the patient responded. Those two additions are what turn a plan into a record of care that closed the loop.
If you trained on SOAP and your unit charts in SOAPIE, the gap is small but it matters. The first four letters are the same. The last two are the part of nursing the SOAP format leaves out: carrying out the plan and judging whether it worked. Below is what each section carries, a full worked example for a post-op patient, and a blank template you can keep.
Key takeaways
- SOAPIE = SOAP plus Intervention and Evaluation. Six sections, not four.
- The two extra letters map to the last two steps of the nursing process: implementation and evaluation.
- Intervention is the action you took. Evaluation is the patient’s measured response to it.
- The worked example below charts a post-op patient with uncontrolled pain, each section annotated.
- No law requires SOAPIE. Your facility picks the format; many use it because it makes nursing reasoning legible.
sections in a SOAPIE note: Subjective, Objective, Assessment, Plan, Intervention, Evaluation
letters SOAPIE adds to SOAP: Intervention and Evaluation
steps in the nursing process the format follows (assessment to evaluation)
What is a SOAPIE note?
It’s a structured nursing note that records a patient problem from what they reported all the way through to how they responded to your care. Six sections, in order.
Subjective is what the patient tells you. Their pain in their words, what they feel, what they’re worried about. “It feels like a 9, worse when I move.” Their voice, not your read of it.
Objective is what you measure and observe. Vital signs, the wound, intake and output, the grimace, the guarding. Numbers and observations a colleague could verify. Per StatPearls, this is the measurable, tangible data: vitals, exam findings, anything you can point to.
Assessment is your nursing judgment about what’s going on. Not a medical diagnosis necessarily, but your conclusion: pain uncontrolled on the current regimen, risk for impaired mobility, anxiety contributing to the pain experience.
Plan is what you intend to do about it. The goal and the approach. “Reduce pain to 4 or below within an hour; reposition, medicate per order, reassess.”
Intervention is what you actually did. This is the first new letter, and it’s where SOAPIE departs from SOAP. You gave the medication at 1410. You repositioned. You raised the head of the bed. You called the provider. Actions, with times.
Evaluation is what happened next. The patient rates pain at 3 forty minutes later. Breathing eased. Or it didn’t, and you escalated. This is the second new letter, and it’s the one most drafts get thin. Evaluation is the proof the care worked, or the trigger to change course.
The base SOAP format, used widely across medicine, stops at the Plan. StatPearls notes that SOAP doesn’t capture how a plan worked over time, which is why extension formats exist that add an explicit evaluation step. Nursing took that further and added two: the doing and the result.
Why does nursing documentation add Intervention and Evaluation?
Because the nursing job doesn’t end at the plan. It includes carrying the plan out and checking whether it helped. The note has to show that.
Look at the nursing process. StatPearls describes it as five sequential steps: assessment, diagnosis, planning, implementation, and evaluation. A SOAP note covers the front half of that. Subjective and Objective are assessment. Assessment is your diagnosis and reasoning. Plan is planning. Then SOAP stops, right at the point where nursing does most of its work.
The implementation step, per StatPearls, “involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.” That’s the I. The evaluation step is where you “reassess to ensure the desired outcome has been achieved,” and “the plan of care may be adapted based on new assessment data.” That’s the E. SOAPIE exists so the note matches the process the nurse is already following.
There’s a reason the order matters, too. The nursing process isn’t a straight line. The Nursing Fundamentals text from Open RN calls it “a continuous, cyclic process that is constantly adapting to the patient’s current health status.” Your Evaluation isn’t the end. A pain score still at 8 sends you back to a new Assessment, a revised Plan, another Intervention. SOAPIE charts one turn of that loop. The next note picks it up.
One opinion, since we’ve seen a lot of notes: the Evaluation section is where good charting separates from box-checking. Anyone can write “medication given.” Whether the patient got better, and what you did when they didn’t, is the part a chart review actually reads.
SOAP vs SOAPIE: what each letter captures, and who uses it
Same first four letters. Two different jobs at the end. The side-by-side:
| Letter | SOAP | SOAPIE | What it captures | Who leans on it |
|---|---|---|---|---|
| S (Subjective) | Yes | Yes | What the patient reports, in their words | Both |
| O (Objective) | Yes | Yes | Vitals, exam findings, measurable data | Both |
| A (Assessment) | Yes | Yes | Clinical judgment about the problem | Both |
| P (Plan) | Yes | Yes | The intended next steps and goals | Both |
| I (Intervention) | No | Yes | The specific actions you carried out, with times | Nurses, who execute the plan |
| E (Evaluation) | No | Yes | The patient’s measured response to the intervention | Nurses, who close the loop |
The split tracks the role. A physician’s SOAP note ends at the Plan because, for the physician, the plan is often the order: prescribe this, refer there, follow up then. The carrying-out happens elsewhere. A nurse is frequently the one who carries it out, at the bedside, that shift, and then watches what happens. So the nurse’s note keeps two more sections to record exactly that. Same patient, same encounter, a longer tail on the documentation because the work has a longer tail.
This is also why you’ll see SOAP in a clinic progress note and SOAPIE on a med-surg floor. It’s not that one is more rigorous. It’s that they document different spans of the same care.
A worked SOAPIE example for a post-op patient
Below is a full SOAPIE note for a routine scenario: a patient on a surgical floor the evening after an open appendectomy, reporting poorly controlled pain. This is an illustrative example written to show the shape. It is not a real patient record, and the medication details are generic for teaching, not a dosing recommendation.
S (Subjective): Patient reports incisional pain at the lower right abdomen, rated 8 out of 10, “sharp and worse when I take a deep breath or try to move.” States the last dose of pain medication “didn’t really touch it.” Reports reluctance to cough or get out of bed because of the pain. Denies nausea. Asks whether “something stronger” is possible.
O (Objective): Post-op day 0, open appendectomy. Vital signs: HR 102, BP 138/86, RR 22 and shallow, temp 37.4 C, SpO2 95 percent on room air. Surgical dressing to RLQ clean, dry, intact. Patient guarding the abdomen, shallow breathing, grimacing with movement. Has not ambulated since returning from PACU. Last analgesic dose documented 3 hours ago.
A (Assessment): Acute post-operative pain inadequately controlled on the current regimen. Shallow, splinted breathing and refusal to mobilize raise the risk of atelectasis and delayed recovery. Pain is the primary barrier to deep breathing and early ambulation.
P (Plan): Goal: reduce reported pain to 4 out of 10 or lower within 60 minutes, and support deep breathing and first ambulation once pain is controlled. Administer analgesia per the provider’s order set, reassess pain and respiratory status, reinforce incentive spirometry, and notify the provider if pain remains uncontrolled after intervention.
I (Intervention): At 2010, administered ordered analgesic per the post-op order set. Repositioned patient, raised the head of the bed, and gave a pillow to splint the incision for coughing. Coached on incentive spirometry and demonstrated splinted deep breathing. Encouraged slow position changes. Set a 40-minute reassessment. Pain pump and call light within reach.
E (Evaluation): At 2050, patient rates pain 3 out of 10 and describes it as “way more manageable.” RR down to 16 and deeper; SpO2 97 percent on room air. Completed incentive spirometry to 1500 mL with splinting and tolerated sitting at the edge of the bed without a pain spike. Goal met. Plan to attempt short ambulation at the next check and continue scheduled analgesia. Will reassess pain before and after activity; escalate to provider if it climbs above 4 again.
Read the I and E sections back to back and you can see the point of the format. The Plan said “reduce pain to 4 or below and support breathing.” The Intervention shows what was actually done and when. The Evaluation shows it worked, with numbers, and sets up the next move. A SOAP note would have ended at “administer analgesia, reassess” and left the rest to memory. The SOAPIE note carries the proof.
Notice what’s in the Intervention that wasn’t in the Plan: the exact time, the splinting pillow, the spirometry coaching. Plans are intentions. Interventions are the record of the shift. Keep them separate. If you find yourself copying the Plan into the Intervention word for word, you skipped the documentation that matters.
A blank SOAPIE note template you can copy
Use this as a skeleton. Fill each section with the patient in front of you, keep Intervention in the past tense with times, and make Evaluation measure against the goal you set in the Plan.
SOAPIE NOTE
Date / Time:
Patient / Room:
S (Subjective)
What the patient reports, in their own words.
Pain rating, symptoms, concerns, relevant statements.
O (Objective)
Vital signs:
Observations / exam findings:
Measurable data (intake/output, wound, labs available):
A (Assessment)
Your nursing judgment about the problem.
What the subjective and objective data add up to.
P (Plan)
Goal (specific and measurable, with a timeframe):
Intended actions to reach it:
I (Intervention)
What you actually did, with times.
Medications given, care provided, teaching, escalation.
E (Evaluation)
Patient's response, measured against the goal.
Did it work? Reassessment. Continue, change, or escalate.Two habits make these notes hold up. First, write the Plan goal so the Evaluation has something concrete to check against. “Pain to 4 or below in an hour” is gradeable; “manage pain” isn’t. Second, don’t let Intervention drift into Plan or Evaluation drift into Assessment. The whole value of six sections is that each one answers a different question.
Can an AI scribe write a SOAPIE note?
It can draft the SOAP part of one well. The line falls in a specific place, and you should know exactly where.
AI Medical Scribe by Patient Square is an ambient AI medical scribe that listens during the visit and hands back a structured SOAP note, ICD-10 suggestions, and a prescription draft — ready to review and sign about two minutes after the visit. That’s a SOAP-structured note. We don’t ship a SOAPIE template or any specialty-specific format, and we’re not going to claim one we don’t have.
Here’s the honest framing, because the format question is a fair one. The same ambient-drafting idea applies to nursing documentation: capture the encounter, structure it, hand back a draft. What the scribe can draft from the conversation is the front of the note, the subjective and objective and your stated assessment and plan. The Intervention and Evaluation are the part you add, because they’re the actions you took at the bedside and the patient’s response you measured afterward, often minutes or hours later. That’s nursing judgment and bedside work, not transcription. A tool that claimed to write your Evaluation for you would be making something up, which is the opposite of what documentation is for.
So the realistic fit is the drafting underneath the format, not a magic SOAPIE button. The ICD-10 codes are suggestions, not automated coding. The prescription piece is a draft only, and it runs through a deterministic safety screener for drug interactions, renal dosing, and pregnancy flags, with a hard block at sign time unless a clinician overrides with an attestation. The audio is processed in memory and discarded the moment the note is drafted, so there’s no recording sitting in an archive. Notes are encrypted in transit and at rest, access is role-scoped and logged, and the notes belong to your practice to export or delete anytime. We map our safeguards to the HIPAA Security Rule and offer a BAA to every customer; our SOC 2 Type II audit is underway. The full posture is on our security page.
For the format mechanics, our mental-health SOAP note guide goes deep on the four-letter version and a grading rubric, and the SOAP note quality guide gives you a six-point scorecard for judging any AI draft against a real encounter, not a demo.
Try it on a real shift’s documentation
A template and a worked example only get you so far. The test is whether a draft holds up against your actual patients and your actual charting standard.
Book a demo to see a structured note appear about two minutes after a sample encounter, then run the 7-day free trial on your own visits and read every draft closely. The format you finish in is yours. What we can do is take the typing off the front of it.