Nursing SOAP notes are essential for healthcare professionals, enabling them to document detailed, reader-friendly medical records efficiently. Here’s a comprehensive guide to the nursing SOAP note framework.

What is a Nursing SOAP Note?

A nursing SOAP note is a type of medical documentation that records information about a patient encounter, including diagnosis, condition, treatment, and progress.

Nursing SOAP notes are a structured format for documenting patient encounters, widely used by nurses and other healthcare providers. These notes are essential for recording patient progress from admission to discharge.

They capture information from patients or caregivers, objective observations, professional assessments, and the corresponding care plan.

The acronym “SOAP” stands for Subjective, Objective, Assessment, and Plan. The SOAP note is a way for healthcare workers to document in a structured and organized way.

This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It reminds clinicians of specific tasks while providing a framework for evaluating information. It also provides a cognitive framework for clinical reasoning.

The SOAP note helps guide healthcare workers in using their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. SOAP notes are essential pieces of information about the health status of the patient and are a communication document between health professionals.

The documentation structure is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

• Subjective (S):

• This section contains the patient’s health and symptoms, along with relevant medical, family, and social history. For example, documenting a patient’s illness history can aid in a more accurate diagnosis.

 

Documentation under this heading comes from the “subjective” experiences, personal views, or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan.

 

• Objective (O):

• This part includes measurable data related to the patient’s condition, such as age, vital signs, and test results. This objective data is crucial for understanding the patient’s current status and guiding clinical decisions.

 

• Assessment (A):

• The healthcare provider diagnoses the patient’s condition based on subjective and objective information. This may include a differential diagnosis, listing potential conditions that match the patient’s symptoms.

 

• Plan (P):

• The final section outlines the treatment plan, which may involve additional tests, specialist referrals, or patient education. It serves as a guide for future healthcare providers and a vital medical record.

 

• Chief Complaint (CC)

 

• The patient reports the CC or presenting problem. This can be a symptom, condition, previous diagnosis, or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail.

 

• Examples: chest pain, decreased appetite, shortness of breath.
• However, patients may have multiple CCs, and their first complaint may not be the most significant. Thus, physicians should encourage patients to state their problems while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis.

 

• History of Present Illness (HPI)

 

• The HPI begins with a simple one-line opening statement, including the patient’s age, sex, and reason for the visit.

 

• Example: 47-year-old female presenting with abdominal pain.

• This is the section where patients can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”:

 

• Onset:

• When did the CC begin?
• Location: Where is the CC located?
• Duration: How long has the CC been going on for?
• Characterization: How does the patient describe the CC?
• Alleviating and Aggravating factors: What makes the CC better? Worse?
• Radiation: Does the CC move or stay in one location?
• Temporal factor: Is the CC worse (or better) at a certain time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?
• It is important for clinicians to focus on the quality and clarity of their patient’s notes rather than include excessive detail.

 

• History

 

• Medical history: Pertinent current or past medical conditions
• Surgical history: Include the year and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history of every person in the patient’s family.
• Social History: An acronym that may be used here is HEADSS, which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

 

Review of Systems (ROS)

 

The Review of Systems (ROS) is a systematic list of questions used to uncover symptoms not mentioned by the patient.

 

• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, decreased right shoulder range of motion

 

Current Medications and Allergies

 

Current medications and allergies can be documented in either the Subjective or Objective sections. Including the medication name, dose, route, and frequency for any documented medications is crucial.

 

Example: Motrin 600 mg orally every 4 to 6 hours for five days

 

Objective

 

This section records the objective data from the patient encounter, which includes:

 

• Vital signs
• Physical exam findings
• Laboratory data
• Imaging results
• Other diagnostic data
• Documentation review from other clinicians

 

A common mistake is confusing symptoms and signs. Symptoms are the patient’s subjective descriptions and belong in the Subjective section, while signs are objective findings related to the symptoms and should be documented in the Objective section. For example, “stomach pain” is a symptom documented under Subjective, whereas “abdominal tenderness to palpation” is a sign documented under Objective.

 

Assessment

 

This section synthesizes subjective and objective evidence to arrive at a diagnosis, assessing the patient’s status by analyzing problems, interactions, and changes.

 

• Problem: List problems in order of importance, often called diagnoses.
• Differential Diagnosis: A list of possible diagnoses, ranked from most to least likely, with the thought process explained. This includes considering less likely but potentially harmful diagnoses.

 

Example:

• Problem 1
• Differential Diagnoses
• Discussion
• Plan for problem 1 (as described in the Plan section)
• Repeat for additional problems

 

Plan

 

This section outlines additional testing, consultations, and treatment steps for the patient’s illnesses, guiding future healthcare providers.

 

• Testing:

• Specify required tests and rationale, including next steps based on positive or negative results.

• Therapy:

• Detail necessary medications and treatments.

• Specialist Referrals:

• Include consultations with other clinicians.

• Patient Education:

• Provide patient counseling and education.

 

A comprehensive SOAP note incorporates all subjective and objective information, accurately assessing it to create a patient-specific plan.

 

Issues of Concern

 

The order of a medical note has been debated. While SOAP notes follow Subjective, Objective, Assessment, and Plan, rearranging to APSO (Assessment, Plan, Subjective, Objective) can be beneficial. APSO initially places the most relevant information for ongoing care, making it quicker for clinicians to find a colleague’s assessment and plan. Studies have shown that APSO can improve primary care physicians’ speed, task success, and usability. This reordering aims to streamline communication without eliminating the essential S to O to A to P relationship.

 

A weakness of Nursing SOAP notes is the need for more documentation for changes over time. Clinical situations often involve evolving evidence, requiring providers to reconsider diagnoses and treatments. An extension of the SOAP model, such as SOAPE, includes the letter “E” to remind clinicians to assess the plan’s effectiveness over time.

 

Clinical Significance

 

Medical documentation now serves multiple needs, resulting in more extensive and detailed notes than fifty years ago. While electronic documentation accommodates these needs, it also allows for large volumes of data, potentially burdening clinicians if the data is not useful or accurate. It is essential to make clinically relevant data easily accessible. The advantage of a SOAP note is its organized structure, ensuring that important information is easy to find. The more succinct yet thorough a SOAP note is, the easier it is for clinicians to follow.

 

The Benefits of Writing Nursing SOAP Notes

 

The structured format of nursing SOAP notes facilitates clinical reasoning by prompting the review of all evidence before reaching a diagnosis and treatment plan. It creates a problem-oriented medical record, offering a clear, detailed history that is easy to understand for anyone reviewing the patient’s notes.

 

Nursing SOAP notes ensure that subjective patient descriptions and objective data are considered, promoting better decision-making and patient care. They also improve communication among caregivers and streamline the documentation process, leading to time savings and more effective healthcare delivery.

 

7 Tips to Support Your Team in Writing Nursing SOAP Notes

 

1. Provide Training: Equip your team with the knowledge to adopt the nursing SOAP note structure through in-person training, video tutorials, and documentation. Different training formats cater to various learning preferences.

 

2. Give Feedback: Regularly review your team’s nursing SOAP notes and provide constructive feedback. Acknowledge and thank them for their good work to encourage continuous improvement.

 

3. Share Examples: Use sample notes to illustrate your desire. Even fictional examples can be valuable. Share poor examples, too, and encourage your team to brainstorm improvements.

 

4. Build Templates: Provide templates to ensure that no critical information is missed in the nursing SOAP notes.

 

5. Use Mobile Apps: Improve note quality by making it easier for your team to update patient progress notes via mobile apps rather than traditional methods.

 

6. Enable Voice-to-Text Technology: Support staff who may struggle with typing due to slow typing speeds, dyslexia, or carpal tunnel syndrome by enabling voice-to-text technology.

 

7. Foster a Supportive Environment: Encourage your team to ask questions and seek help without fear of judgment. Create a positive culture where everyone is motivated to improve their documentation skills.

 

By implementing these strategies, you can help your team write high-quality nursing SOAP notes efficiently, leading to better patient care and streamlined medical documentation.

 

Who Developed Nursing SOAP Notes?

 

Dr. Lawrence Weed pioneered nursing SOAP notes in the 1960s to introduce a standardized approach to medical documentation.

Initially part of the Problem-Oriented Medical Record (POMR), SOAP notes allowed healthcare professionals to systematically document specific problems or diagnoses.

While the POMR and SOAP notes are now considered distinct types of documentation, the SOAP format has been widely adopted across various healthcare disciplines, including nursing.

 

What is the Purpose of Writing a Nursing SOAP Note?

 

The primary goal of a nursing SOAP note is to provide a continuous, structured record of patient encounters. These notes enable healthcare teams to track patient progress, symptoms, care provided, and responses to treatment efficiently. They consolidate vital signs, test results, patient status changes, and updates to the treatment plan in one accessible document for all providers.

 

What is the Difference Between a Nursing SOAP Note and a Nursing Progress Note?

 

While nursing SOAP and progress notes are often used interchangeably, they serve slightly different purposes. Progress notes are typically used for initial patient contact, documenting histories, physicals, and subsequent SOAP notes.

Nursing SOAP notes follow the structured format of Subjective, Objective, Assessment, and Plan, ensuring a consistent method for documenting ongoing patient encounters. In contrast, nursing progress notes often feature a free-text field for more narrative documentation.

 

4 Advantages of Nursing SOAP Notes

 

Advantage #1: Facilitates Clinical Reasoning

The structured format of SOAP notes encourages nurses to review all evidence—subjective and objective data and assessment findings—before reaching a nursing diagnosis. This comprehensive review helps develop individualized care plans tailored to the patient’s needs, ultimately improving patient outcomes.

 

Advantage #2: Promotes Active Listening

SOAP notes require the inclusion of subjective data, prompting nurses to engage in active listening. This involves paying attention to verbal and nonverbal patient cues, fostering a trusting relationship, and ensuring timely, appropriate care.

 

Advantage #3: Creates a Detailed Medical History

SOAP notes help build a problem-oriented record that the entire interdisciplinary team can use. By documenting patient complaints, symptoms, and responses to interventions, these notes create a comprehensive timeline crucial for determining expected outcomes.

 

Advantage #4: Enhances Communication Between Nurses and Doctors

Nursing assessments and findings are vital for doctors and nurse practitioners making clinical diagnoses. Nursing SOAP notes provide a clear, structured way for nurses to communicate their observations and assessments, facilitating effective collaboration and patient care.

 

3 Disadvantages of Nursing SOAP Notes

 

While nursing SOAP notes offer many advantages, there are some notable disadvantages. Here are three main drawbacks associated with using SOAP nursing notes:

 

 DISADVANTAGE #1: The Order of the SOAP Format

Many healthcare providers question the order of the SOAP format and suggest rearranging it to APSO (Assessment, Plan, Subjective, Objective). While the same information is documented, this reordering can make it easier for providers to quickly find pertinent data and understand the patient’s current health status and care plan before diving into the subjective and objective details.

 

 DISADVANTAGE #2: Addressing Multiple Complaints

Patients often present with multiple symptoms or concerns. The SOAP format typically focuses on one chief complaint, which can be limiting. While other issues are documented, they are listed in order of priority. This can be confusing, especially in hospitals where multiple clinicians and nurses care for the same patient across different shifts.

 

DISADVANTAGE #3: Time-Consuming Data Gathering

Reviewing and updating SOAP notes over time can be time-consuming. Clinicians must sift through multiple entries to track patient progress and treatment efficacy. This extensive review process can detract from direct patient care and immediate assessments, making it less efficient in fast-paced environments.

 

What Elements Should Be Included in a Nursing SOAP Note?

 

Nursing SOAP notes contain four key elements: Subjective Data, Objective Data, Assessment, and Plan of Care. Each component should be concise and relevant to the patient’s current concerns.

 

1. Subjective Data (S)

Subjective data includes information from the patient about their health history and current symptoms. It also details the patient’s family, social, and medical history. This data is crucial for making accurate diagnoses and developing effective care plans.

 

2. Objective Data (O)

Objective data involves measurable or observable information about the patient’s condition, such as vital signs, diagnostic test results, and physical observations. This data provides a factual basis for the patient’s health status and helps form accurate assessments.

 

3. Assessment Findings (A)

The assessment combines subjective and objective data to form a diagnosis. It involves analyzing the collected information to understand the patient’s condition better and identify any changes or developments.

 

4. Plan of Care (P)

The plan of care outlines the treatment strategy based on the assessment. This section may include orders for further testing, patient education, referrals to specialists, and other necessary interventions or support services.

 

What Elements Should Not Be Included in a Nursing SOAP Note?

 

To create effective nursing SOAP notes, avoid including the following elements:

 

1. Irrelevant Information

Focus only on the patient’s current condition and complaints. Avoid documenting details unrelated to the immediate health issues.

 

2. Speculations

Document facts as presented by the patient, caregiver, or objective data. Avoid speculating about the patient’s thoughts or feelings.

 

3. Confusing Pronouns

Use clear and specific titles or names instead of pronouns to avoid confusion. For example, instead of writing, “She instructed the client,” write, “The clinician instructed the client.”

 

4. Judgmental Statements

Document findings objectively and without judgment, even if you believe the information provided is inaccurate. For instance, instead of “The mother is mistaken,” write, “The mother reports the child began walking at five months of age.”

 

5. Slang Terms or Unprofessional Phrases

Maintain a professional tone and avoid slang or casual language. For example, replace “Pt. walked and had an awesome time” with “Pt. ambulatory in the hall with minimal assistance; displayed a cheerful effect and tolerated the walk well.”

 

By adhering to these guidelines, nursing SOAP notes can remain clear, concise, and useful for all healthcare providers involved in patient care.

 

 

How to Write a Perfect Nursing SOAP Note: A Step-by-Step Guide

 

Creating the perfect nursing SOAP note involves four main steps: gathering subjective data, collecting objective data, performing a nursing assessment, and creating a nursing care plan. Here’s a detailed breakdown of each step to help you write an effective SOAP note.

 

Gathering Subjective Data

 

Step #1: Interview the Patient

Begin by talking with your patient to gather subjective data. This includes what the patient experiences from their perspective. Ask about pain, shortness of breath, or decreased appetite, and record their responses.

 

Step #2: Use the Mnemonic Device OLDCARTS

OLDCARTS helps remember key questions to ask about symptoms:

• O: Onset – When did the symptoms start?
• L: Location – Where is the symptom located?
• D: Duration – How long has the symptom been present?
• C: Characterization – Describe the pain (dull, sharp, etc.).
• A: Aggravating/Alleviating Factors – What makes it better or worse?
• R: Radiation – Does the symptom move?
• T: Temporal Patterns – Does it occur at specific times?
• S: Severity – Rate the pain on a scale of 1 to 10.

 

Step #3: Collect Personal and Family Medical History

Ask about the patient’s medical and surgical history, including relevant family history. Focus on information pertinent to the patient’s current condition.

 

Step #4: Verify Medications and Allergies

Record all medications the patient is taking, including over-the-counter drugs and supplements. Include the name, dosage, and frequency of each medication.

 

Gathering Objective Data

 

Step #5: Measure the Patient’s Vital Signs

Start by measuring vital signs. If any readings are abnormal, double-check them for accuracy and document the verification process.

 

Step #6: Document Objective Findings

Record your findings objectively. For instance, instead of “Patient reports knee pain,” write “Tenderness noted in the right knee with visible redness and bruising.”

 

Step #7: Update Test Results

Incorporate new laboratory or diagnostic test results into the note. Ensure that all relevant information is documented accurately.

 

Performing an Assessment

 

Step #8: Observe for Changes Since the Last Assessment

Review the patient’s chart for previous notes and observe any changes in the patient’s condition since the last assessment.

 

Step #9: Prioritize Patient Complaints

Focus on the patient’s complaints in order of severity. Use subjective and objective data to determine the most pressing issues.

 

Step #10: Form a Nursing Diagnosis

Based on the gathered data, a nursing diagnosis is formed. For example, if a diabetic patient reports elevated blood glucose and symptoms of hyperglycemia, a possible diagnosis could be “Risk for Unstable Blood Glucose Levels.”

 

Step #11: List the Rationale for the Diagnosis

Provide reasons for the diagnosis based on the collected subjective and objective data.

 

Creating a Plan

 

Step #12: List Relevant Nursing Interventions

Detail the interventions necessary for each diagnosis. For a patient with uncontrolled diabetes, interventions might include monitoring blood sugar levels, educating the patient on medication compliance, and referring them to a nutritionist.

 

Writing Your Note

 

Step #13: Record Pertinent Patient Information

Start your note with the patient’s name, age, sex, and chief complaint. For example, “54 y/o male presenting to clinic with abdominal pain.”

 

Step #14: Organize Information According to the SOAP Format

Structure your note according to your healthcare facility’s preferences, whether that’s a bulleted format or paragraphs. Ensure all relevant information is under the appropriate subheading and update subsequent notes with any changes.

 

Following these steps, you can write a thorough and effective nursing SOAP note that facilitates better patient care and communication among healthcare providers.

 

Perfect Examples of Nursing SOAP Notes

 

Are you looking for perfect examples of nursing SOAP notes? Below are five comprehensive examples to guide you.

 

Example #1: Patient with Chest Pain and Shortness of Breath

 

Subjective:

Mr. Jones, a 71-year-old white male, presented to the ER with intermittent chest pain and shortness of breath (S.O.B.). He reports that the pain has lasted for the past six hours. Mr. Jones has a history of hypertension (HTN), high cholesterol, and Type 1 diabetes mellitus (DM). Family history includes heart attacks, HTN, and diabetes. After a 12-lead EKG, lab tests, and a chest CT, he was diagnosed with transient angina. He was treated and stabilized in the ER and transferred to cardiac care for observation. Mr. Jones continues to experience S.O.B. with ambulation but currently denies chest pain. He has no known allergies, and his medication list has been provided and updated.

 

Objective:

The patient is alert and oriented x4, with pulses + x4 extremities. Vital signs: BP 146/90, R 24, HR 88, T 98.4, SpO2 92%. Lungs are clear to auscultation bilaterally (CTAB), and heart rate is regular. Skin is pale, warm, and dry, with slight cyanosis noted around the lips. The patient walked from his room to the nurse’s desk with some S.O.B. on exertion.

 

Assessment:

Activity intolerance as evidenced by decreased SpO2, elevated respiratory rate, and cyanosis of the lips.

 

Plan:

• Apply O2 per nasal cannula at 2L continuously.
• Elevate the head of the bed at least 45 degrees.
• Encourage deep breathing exercises.
• Continue to monitor vital signs and patient complaints.
• Ensure the call light is in place with instructions to call for assistance.

 

Example #2: Patient with Productive Cough and Fever

 

Subjective:

Patient M.S. presented to the clinic with a persistent productive cough for five days. She describes the initial symptoms as a common cold, but they have worsened in the last 48 hours. Over-the-counter cough suppressants provide minimal relief. She also reports chest tightness and difficulty breathing deeply, with a fever of 101.6°F. She denies chills and hemoptysis. Sputum is thick, white, and slightly yellow. She also reports yellow nasal mucus and facial tenderness.

 

The patient denies a history of chronic pulmonary issues but has been a smoker for 20 years. She has Type 2 diabetes, is well-controlled on Ozempic, and takes aspirin prophylactically. No other medications or significant personal/family medical history. No known drug or food allergies.

 

Objective:

Skin is pink, warm, and dry. Slight dyspnea on exertion was noted when ambulating. Vital signs: BP 120/78, P 84, R 26, T 100.2. Lungs are clear to auscultation bilaterally. Heart rate is steady with normal S1 and S2 sounds. No edema, pulses present x4 extremities. Chest X-ray negative for effusion or pneumonia. The sinus X-ray shows soft tissue density, which causes sinus cavity expansion.

 

Assessment:

Recent onset of productive cough, purulent nasal drainage, facial tenderness, and low-grade temperature. Chest X-ray negative for pneumonia. No edema suggests the absence of congestive heart failure (CHF).

 

Plan:

• Treat with an albuterol inhaler, two puffs every 6 hours, and 500 mg of Amoxicillin twice daily per MD orders.
• Educate the patient on the appropriate use of the inhaler, coughing, and deep breathing exercises.
• Encourage smoking cessation and follow-up in the clinic if there is no improvement or if symptoms worsen.

 

Example #3: Patient with Skin Outbreak

 

Subjective:

Patient V.H., a 60-year-old black male, presented to urgent care with a rash lasting over a week. The rash first appeared on his lower back near the spine and has spread to his right abdomen. Initially painless, he now describes it as a “burning sensation” aggravated by clothing. He has been taking acetaminophen with little relief and rates the pain as 6/10.

 

The patient has a history of HTN and bilateral lower extremity edema, managed with Metoprolol and Lasix.

 

Objective:

Patient is alert and oriented x4 and appears in no acute distress despite reports of pain. Vital signs: BP 126/78, P 70, R 14, T 98.6, SpO2 98%. Erythematous rash with clustered vesicles, some fluid-filled and others with honey-colored crusts.

 

Assessment:

Painful rash with a right lateral distribution and fluid-filled vesicles suggests herpes zoster. The absence of fever reduces the likelihood of cellulitis.

 

Plan:

• Continue acetaminophen for pain relief.
• Educate the patient that symptoms may persist after the rash resolves and that he is no longer contagious once all lesions crust.
• Advise follow-up if pain worsens, fever develops, or lesions do not resolve within four weeks.
• Instruct on keeping open sores covered and not disturbing scabs or blisters.

 

Example #4: Clinic Follow-Up for Diabetes Patients

Subjective:

Ms. H., a 49-year-old woman, is here for a follow-up appointment for Type 1 diabetes management. Six months ago, her A1C was 6.5, and she did not reach her goal on Metformin. She currently takes Mounjaro and reports blood sugar levels between 70 and 100. She denies symptoms of polydipsia, polyphagia, and polyuria and is trying to make healthier food choices despite a busy work schedule.

 

She has hyperlipidemia, managed with Simvastatin and other medications, including Zoloft and Folic Acid.

 

Objective:

The patient has a pleasant affect, is alert and oriented x4, and has no complaints. Vital signs: BP 130/80, P 68, R 18, T 98.1. Recent lab results show an A1C of 5.4, normal CBC, CMP, and improved lipid panel with LDL of 125. Skin is warm, dry, and intact, and diabetic foot assessment is unremarkable.

 

Assessment:

Follow-up for Type 1 Diabetes Mellitus. Blood glucose levels are within normal limits, and hyperlipidemia and diabetes are well controlled with diet and medication.

 

Plan:

• Continue current medications and daily blood sugar monitoring.
• Repeat A1C and lipid panel in six months.
• Refer to a nutritionist for dietary planning.
• Follow up in the clinic with any new symptoms or concerns.

 

Example #5: Patient with a History of Congestive Heart Failure

 

Subjective:

Patient G.P., a 64-year-old male, presented to the ED with shortness of breath (S.O.B.) at rest and swelling of both feet and legs. He admits to non-compliance with his Lasix medication due to frequent urination and continues to smoke. His spouse reports worsening swelling and cough. The patient denies pain, fever, aches, vomiting, or diarrhea.

 

Medical history includes CHF, HTN, and atrial fibrillation, with medications including Lasix (not taken), Lopressor, and Losartan.

 

Objective:

The patient is mildly agitated, with pale skin and clammy. Vital signs: BP 160/94, P 82, R 24, T 98.3, SpO2 92%. Weight increased from 243 to 249 lbs. Bowel sounds active, abdomen non-tender—bilateral lung bases with crackles, no retraction. Pulses present x2 upper and lower extremities. 3+ pitting edema in lower extremities. EKG shows atrial fibrillation, and CXR shows cardiomegaly.

 

Assessment:

Likely acute exacerbation of CHF based on orthopnea, S.O.B., BLE edema, weakness, and fatigue. Smoking history may indicate COPD, but CHF is more likely.

 

Plan:

• Admit to telemetry for O2 support and diuresis evaluation.
• Conduct a cardiac workup, including an echocardiogram and stress test.
• Start Lasix IV twice daily.
• Educate the patient on medication compliance and smoking cessation and offer a nicotine patch.

 

By using these detailed nursing SOAP note examples, you can ensure accurate and effective patient documentation.

 

5 Most Common Mistakes to Avoid While Writing a Nursing SOAP Note

 

When writing a nursing SOAP note, following the proper format is crucial to ensure accuracy and clarity. Here are the five most common mistakes nurses make when writing these notes and how to avoid them.

 

Mistake #1: Not Naming the Source of Information

 

About the Mistake: Failing to specify the source of information can lead to unclear documentation and may hinder the patient’s care process.

 

How to Avoid: Always document exactly what is reported and by whom. For instance, if the patient reports feeling nauseated, write, “Pt. reports nausea X2 days.” If a family member provides information, document it as “Pt.’s spouse reports pt. Seems confused at times.”

 

Mistake #2: Not Providing Supporting Objective Data

 

About the Mistake: The objective section should include measurable outcomes and observations. Omitting this data makes the note less useful.

 

How to Avoid: Avoid general statements that lack supporting data. Instead of writing, “Pt. responds well to verbal cues,” specify the actions taken, such as “Pt. responds to verbal cues by following directions for opening utensils.”

 

Mistake #3: Repeating Subjective and Objective Data in the Assessment Section

 

About the Mistake: The assessment section should analyze the patient’s progress and test results, not repeat previous information.

 

How to Avoid: Review the subjective and objective data before writing the assessment. Document your analysis of the patient’s progress, any new symptoms, and the implications of test results.

 

Mistake #4: Rewriting the Whole Treatment Plan

 

About the Mistake: Repeating the treatment plan in the plan section wastes time and space.

 

How to Avoid: Use the plan section to outline the next steps in patient care based on your assessment. For example, if the patient responds well, document “Continue current treatment plan; re-evaluate progress.” If not, specify new goals and objectives.

 

Mistake #5: Assuming the First Complaint is the “Chief” Complaint

 

About the Mistake: The first symptom reported may not always be the primary issue.

 

How to Avoid: Gather comprehensive information to determine the primary complaint. This is crucial as all other note sections build on this data.

 

Bonus! 5 Expert Tips for Writing Nursing SOAP Notes Faster

 

Efficiently writing a nursing SOAP note without sacrificing quality is essential. Here are five tips to help you do just that.

 

Tip #1: Write Your Note at an Appropriate Time

 

Find a distraction-free time to write your note. Use pen and paper to jot down important information during patient assessment and write the complete note as soon as possible.

 

Tip #2: Use Direct Statements, Avoiding Overly Wordy Content

 

Keep your notes clear and concise. Avoid lengthy statements and focus on direct insights.

 

Tip #3: Be Specific and To the Point

 

Document only pertinent information without personal opinions or unnecessary details.

 

Tip #4: Document Each Patient Encounter as Soon as Possible

 

Documenting immediately after patient encounters helps avoid forgetting crucial details and ensures timely and accurate notes.

 

Tip #5: Connect Interventions with Your Diagnosis

 

Ensure that your documentation reflects the care provided, essential for legal proof and reimbursement. Write with reimbursement in mind to avoid having to make corrections later.

 

A nursing SOAP note is essential for accurate and effective patient care documentation. This article has provided an overview of a nursing SOAP note, common mistakes to avoid, and expert tips for writing them efficiently. Remember to follow your facility’s protocols and the key principle: if it’s not documented, it didn’t happen!

 

Frequently Asked Questions Answered by Our Expert on Nursing SOAP Notes

 

1. Who Can Write a Nursing SOAP Note?

 

Nurses, nursing students, and other healthcare providers can write nursing SOAP notes.

 

2. When Should You Write a Nursing SOAP Note?

 

You should write a nursing SOAP note whenever you need to document your patient’s progress. The frequency of notes will depend on how often the patient is seen or assessed.

 

3. Do Nurses Write SOAP Notes Every Shift?

 

In facilities where nursing SOAP notes are used, nurses typically write a SOAP note at least once each shift.

 

4. How Long Should Nursing SOAP Notes Be?

 

Most nursing SOAP notes are one to two pages long for each patient encounter. Each section may contain one to two paragraphs.

 

5. What is the Most Important Part of a Nursing SOAP Note?

 

All parts of a nursing SOAP note are equally important. It takes a combination of subjective and objective data for the nurse to apply critical thinking and a systems approach to assessing a patient and implementing care.

 

6. Can I Use Abbreviations in a Nursing SOAP Note?

 

Yes, you may use abbreviations for medical terms in a nursing SOAP note. However, it is best to use complete words when possible. If you need help with using an abbreviation correctly, it is always best to spell out the words.

 

7. What Tense Should a Nursing SOAP Note Be Written In?

 

Nursing SOAP notes should be written in the present tense as they document each patient encounter.

 

8. Are Nursing SOAP Notes Handwritten or Printed?

 

If your facility does not use Electronic Health Records (EHR), you may need to write your notes manually. Nursing SOAP notes can be handwritten in cursive or print, but the most important thing is to ensure your note is legible.

 

9. How Do You Sign Off on a Nursing SOAP Note?

 

You should sign off on a nursing SOAP note with your name and credentials.

 

10. What Happens If I Forget to Write a SOAP Note on Time?

 

Failure to write a nursing SOAP note on time can negatively affect nurses, healthcare teams, and patients. If you must remember to write a note and have left work, call your nursing supervisor immediately to report the oversight and provide any important patient information. Upon returning to work, complete your note by recording the date of the events and necessary information, and document that it is a late entry. For example, you may write, “8/9/23 (Late entry for care provided on 8/8/23)….”

 

11. Can a Nursing Student Write a Nursing SOAP Note?

 

Yes, nursing students can write nursing SOAP notes. It is customary for the nursing instructor to sign behind the student at the end of the note.

 

 

Nursing SOAP Notes Made Simple

 

A well-written nursing SOAP note enhances care quality by facilitating clinical reasoning and improving communication among healthcare team members. With proper training and support, your team can write patient notes more quickly and efficiently than ever.

 

Simplify Nursing SOAP Notes with nursingbuddie.com

 

Nursingbuddie.com care management software streamlines the process by allowing you to build customizable progress note templates that adhere to the nursing SOAP note format or any other preferred format. You can create templates tailored for different client groups to ensure the most clinically relevant data is included.

 

With nursingbuddie.com’s user-friendly mobile app and voice-to-text technology, creating progress notes has never been easier.

 

Additional Features of nursingbuddie.com

 

nursingbuddie.com offers a comprehensive range of features beyond progress note templates:

 

• Rostering: Efficiently manage staff schedules.
• Funds Management: Keep track of client funds seamlessly.
• Accounting Integrations: Simplify financial processes with integrated accounting.
• Compliance Documentation: Receive notifications for compliance document expirations to stay up-to-date.

 

By leveraging these features, nursingbuddie.com enhances your healthcare team’s overall efficiency and effectiveness, ensuring better patient care and streamlined operations.

Nursing SOAP notes are a critical tool in healthcare, providing a structured and comprehensive method for documenting patient encounters.

Nursing SOAP notes play a vital role in delivering high-quality, patient-centered care by facilitating clinical reasoning, promoting active listening, creating detailed medical histories, and enhancing communication between healthcare providers.