7 - SOAP Documentation Guidelines
Health and Nutrition Assessment Handbook (HNAH)
7 - SOAP Documentation Guidelines
Revised 04/2026
To ensure continuity of care, subjective, objective, assessment and plan (SOAP) notes are required for documentation of the nutrition care plan for all participants at certification, mid-certification assessment (MCA) and for high-risk follow-up. This SOAP note tool may help develop appropriate SOAP notes. Utilize the Health and Nutrition Assessment Handbook (HNAH) for approved standard abbreviations for writing SOAP notes. Refer to policy 8.1.070 Certification in the WIC Operations Manual (WOM).
Quality nutrition education documentation should always be:
- Consistent with training, policies and resources.
- Clear and precise so the reader easily understands.
- Concise and well organized, following a logical order without duplication and unnecessary information.
- Complete to create a picture of the participants, the services provided over time and outline a plan for future services.
SOAP note
Subjective (S)
Information given by the participant or caregiver.
- Thoughts, feelings and complaints.
- Dietary intake or eating habits.
- Health comments and concerns (e.g., substance use, vitamin use, tobacco and nicotine use, oral health assessment, immunization refusal).
Participant responses and statements may include, but are not limited to:
| Infants | Children | Women |
|---|---|---|
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|
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Objective (O)
Objective observation and measurements taken by WIC staff or the health care provider (HCP).
- Anthropometrics, biochemical and risk factor data.
- The Management Information System (MIS) will automatically populate the most recent data entered in the system when using the SOAP note template.
- HCP diagnosis (including self-reported), medications and recommendations.
- Document the HCP’s name and contact information, if prescribed, the name of the special diet, formula or medication and any follow-up plans with the HCP.
- Clinical observations (i.e., signs and symptoms).
Assessment (A)
Professional staff’s assessment of subjective and objective data.
- The participants’ comprehension and motivation.
- Oral health assessment findings.
- Vitamin adequacy (risk factors 411.11, 425.8 and 427.4).
- Referral outcome.
- Goal progress.
- Summary and evaluation for assigning risk factors.
- Justification for resolving high-risk risk factors.
Plan (P)
Plan for intervention and follow-up.
- Intervention to address risk factors and nutritional status.
- Food package tailoring.
- Discussion, education and resources.
- Nutrition education delivery medium (e.g., group education, individual, telephone).
- Educational materials used and given to the participant.
- Referrals and Resource List provided.
- SMART goal.
- Plans for follow-up.
SOAP note examples
Professional staff will use their professional judgment and critical thinking to ensure notes are complete and thorough based on the type of appointment and conversation with the participant. Each note will be different and include information specific to the type of appointment.
Non-high-risk note
| Section | Example |
|---|---|
| S | The mom reports that the doctor diagnosed her 7-month-old with gastroesophageal reflux disease (GERD) and advised that cereal in the bottle helps with reflux. The mom also reports that her baby eats well and likes mashed potatoes and other soft table foods. She offers six to eight-ounce bottles of Similac Advance four to five times a day. She mixes the formula with boiled tap water from the city. |
| O | Diagnosis: GERD, Dr. Dave Smith at Northeast Health Center (573-555-5555). |
| A | The current formula and cereal feeding method is an inappropriate feeding practice. Vitamin D is adequate. Fluoride cannot be assessed; she does not know if her water is fluoridated. Mom did not accomplish the previous goal of breastfeeding for six months. |
| P | Discussed appropriate feeding method and suggested Enfamil A.R. formula. Provided WIC-27 and referred to HCP. Mom is receptive. Goal: Offer cereal by spoon twice daily instead of from the bottle for the next two weeks. Follow up on the referral to the HCP for a new formula and progress toward the goal. Gave the Starting Your Baby on Solids handout. |
High-risk note completed by nutritionist
| Section | Example |
|---|---|
| S | The mom reports Jessie is a 2-year-old picky eater, especially with meat. She would rather drink milk than eat. The mom allows Jessie to drink as much milk as she wants. She usually has five to six cups a day. The mom denies any current illness but notices tooth decay. The mom reports that lead testing was completed for the 2-year-old well-child visit, and the HCP will send the results. The mom denies routinely eating non-food items. |
| O | Hemoglobin: 9.9. Risk factors: 103, 201. |
| A | Excessive milk intake is likely interfering with appetite and iron absorption. The Dietary Guidelines for Americans (DGA) recommend only two cups per day for this age group. Slight tooth decay was noted. Mom will need ongoing support and encouragement to reduce milk intake. Vitamin D intake is adequate with this milk intake. |
| P | Discussed excessive milk intake and the recommendation to limit to two cups per day. Provided an electronic copy of How to Eat More Foods with Iron and encouraged mom to offer these foods at meals and snacks. Dental and HCP referrals were provided. Substituted $3 CVB for juice, per personal preference. Goal: Limit milk to two cups daily over the next two months. Follow up in two months to check weight, appetite, lead result and referral outcome. |
Where to document?
Many subjects that must be documented may depend on the conversation and response to determine where in the SOAP note to document the information received from the participant. For example, conversations about lead, prenatal vitamins and blood work may be documented as follows:
Lead
| Section | When to document here | Example |
|---|---|---|
| S | When noting what the participant said. | Participant’s mom states they have not had a blood lead test completed. |
| O | If the lead test was completed at the HCP. | Lead test completed at Dr. Miller’s office. |
| A | If there are concerns about the result of the lead test. | Lead test value was high; the participant has not followed up with the HCP about this concern, as referred from the last appointment. |
| P | When the participant is referred to a lead testing program or when the goal is to have the participant's lead levels tested. | Referred to LPHA for lead testing; the goal is to complete lead testing by the next appointment in May. |
Prenatal vitamins
| Section | When to document here | Example |
|---|---|---|
| S | What the participant states they are taking. | States she takes a prenatal vitamin about five times per week and does not know the brand. |
| A | The professional staff’s judgment on vitamin adequacy. | Prenatal vitamins are inadequate for iron. |
| P | The referral to the HCP for adequate vitamins. | Referred to HCP for a recommendation on a prenatal vitamin that would meet her vitamin needs without causing nausea. |
Blood work
| Section | When to document here | Example |
|---|---|---|
| S | When noting what the participant said. | Participant declined hemoglobin (Hgb) screening today due to personal belief; mother states they do not want the child to undergo the test. |
| O | The blood work results included in the MIS or delayed bloodwork. This is auto-populated. | 04/01/2026 Delayed Bloodwork. 04/26/2026 Hgb: 11.6. |
| A | The professional evaluation of Hgb results or a nutritionist’s reasons for resolving the high-risk risk factor associated with blood work. | Low Hgb today. She is taking a prenatal vitamin without iron and has had an aversion to meat during her first trimester, which could have contributed to the low Hgb. Resolved high-risk RF 211; Mom has successfully added calcium- and iron-rich foods to the child’s diet based on education provided at the last appointment. HCP is closely following the high lead levels and rechecked with a venous blood lead test, which Mom reported was WNL. |
| P | The referrals, education provided and plans for rechecking. | Provided education on low Hgb and gave an Iron Foods handout. Will recheck Hgb in six months at MCA. |