Nursing SOAP note is what nurses use to separate all the insignificant information about patients from significant information. It shows what is happening to patients in a neat and organized way. This makes it easier for other healthcare members to understand and care for patients more effectively.
What Does SOAP Stand For?
There are four components that form these notes that make up the acronym S-O-A-P:
S is for subjective, or what the patients say about their situation. It includes a patient's complaints, sensations or concerns. In most cases, it is the reason the patient came to see the doctor
Here are some examples:
The patient complained of a severe pain on the right side of his head.
The patient stated having a sore throat and chills.
The patient mentioned feeling itchy all over her body.
The patient was worried about not being able to sleep for three days.
The patient wanted to see the doctor for his annual physical.
O is for objective, or what the nurses 'observe' in the patients. It includes facial expressions, body language and test results. Nurses can conduct a physical examination where more data is obtained. Some examples include:
The patient grimaced when moving his right leg.
The patient avoided direct eye contact.
The patient's blood pressure reading was high.
The heartbeat sounds irregular.
The skin felt cool and clammy.
A is for analysis or assessment. Nurses make assumptions about what is going on with the patients based on the information they obtained. Although these assessments are not the medical diagnosis that health care providers make, they still identify important problems or issues that need to be addressed.
Some examples include:
The patient is at risk for stroke.
The patient seems very anxious.
The patient is having difficulty breathing.
The wound looks like it is infected.
The patient did not have a physical last year.
P is for plan. Nurses make decisions about how to provide care based on the patient's specific needs and abilities. The interventions also have to be realistic and measurable so their effectiveness can be evaluated. nursing soap note This can include treatments, medications, education, and consults to other members of the healthcare team.
Nursing SOAP Note Format: How to Write
Writing in a nursing soap note format allows healthcare practitioners to conduct clear and concise documentation of patient information. nursing soap note This method of documentation helps the involved practitioner get a better overview and understanding of the patient’s concerns and needs.
Below are ways you can effectively write a SOAP note:
Subjective – What the Patient tells you
This section refers to information verbally expressed by the patient. Take note of the patient ’s complete statement and enclose it in quotes. Recording patient history such as medical history, surgical history, and social history should also be indicated as it can be helpful in determining or narrowing down the possible causes. It can be written like this:
Subjective: Patient states: “My throat is sore. My body hurts and I have a fever. This has been going on for 4 days already.”
Patient is a 23-year-old female. Prior to this, patient says she had a common cold and whooping cough then progressed to the current symptoms.
Objective – What You See
This section consists of observations made by the clinician. Do a physical observation of the patient’s general appearance and also take account of the vital signs (i.e. temperature, blood pressure etc.). If special tests were conducted, the results should be indicated in this section. Using the previous example, we can write the objective like this:
Objective: Vital signs represent a temperature of 39°, BP of 130/80. Patient displays rashes, swollen lymph nodes and red throat with white patches.
Assessment – What You Think is going on.
This section tells the diagnosis or what condition the patient has. The assessment is based on the findings indicated in the subjective and objective section. This section can also include diagnostic tests ordered (i.e. x-rays, blood work) and referral to other specialists. Using the same example, the assessment would look like this:
Assessment: This is a 23-year-old female with a history of common cold and whooping cough and reporting for a sore throat, fever, and fatigue. Clinical examination suggests bacterial pharyngitis due to swollen lymph nodes and the presence of white patches on the throat.
High Fever (caused by pharyngitis)
Plan – What You Will Do about It
This section addresses the patient’s problem identified in the assessment section. Elaborate on the treatment plan by indicating medication, therapies, and surgeries needed. This section can also include patient education such as lifestyle changes (i.e. food restrictions, no extreme sports etc). Additional tests and follow up consultations can also be indicated. With the same example, the plan section can be written like this:
Acetaminophen – take every 6 hours x 5 days
Penicillin (500mg) – once a day for 5 days
No labs or consults. Follow up after 5 days if symptoms persist or worsen. Drink plenty of water and intake Vitamin C
What is auditor and how can I Use it for Nursing SOAP Note?
Healthcare professionals can use auditor, the world’s #1 inspection software, to digitally gather SOAP notes and improve the quality and continuity of patient care.
Create SOAP notes in digital format and easily update and share with teammates
Collect photo evidence for a more informative and descriptive patient record
Save completed SOAP reports in safe cloud storage
Easily share your findings with other healthcare clinicians and avoid losing track of patient records by securely saving it in the cloud using auditor
Facilitate digital sign-offs to verify acknowledgment of SOAP assessment.
5 Tips and Tricks for Writing Successful Nursing Soap Note
1. Don't assume the first complaint is the chief complaint
The Subjective section of SOAP notes is supposed to provide context for later sections, so if nurses record a chief complaint that is not aligned with the Assessment and Plan, the entire note may read off kilter. Authors Valerie Lew and Sass a Ghassemzadeh caution nurses against assuming the first reported complaint is the chief complaint. Instead, they encourage clinicians to have patients share information about all their complaints to sass out what might be the primary issue.
2. Double check your EMR entries for errors
Nursing SOAP notes may seem like second nature if you're an experienced RN, but make sure you take time to proof your work. Something as simple as a typo can change the entire meaning of your note, and there have been cases where nurses wrote pristine SOAP notes in the wrong patient's online chart. A few minutes of extra care can go a long way to reducing these types of errors.
3. Connect diagnosis with intervention
Veronica Anza lone, RN, has 16 years of healthcare experience. She's reviewed a lot of charts from many perspectives, and says it's important for nurses to chart with reimbursement in mind."
The last seven years of my career have been spent working within the healthcare revenue cycle," says Anza lone, "including five years reviewing medical records for medical necessity and coding appeals. In many instances, a case was made for appropriate reimbursement because the nurses caring for the patient, whose claim was in question, carefully connected their nursing interventions and rationales to their assessment."
4. Don't make assumptions about the person reading your notes
Anza lone also says nurses shouldn't make assumptions about who might read charts in the future. It's not always another clinician; lawyers, reimbursement decision makers and others may read nursing SOAP notes."
With my experience in retrospective chart review, detail matters," says Anza lone. "As we are taught in school: if it is not documented, it did not happen. A nurse should not take for granted that the person reading their note will know that the standard of care has been met."
5. Limit the Assessment portion of soap nursing notes to appropriate information
Remember that nursing SOAP notes should be comprehensive, but concise. That requires including the appropriate information in each section, but leaving out extraneous notes or opinions that don't belong there. For example, the Assessment should only include notes regarding the diagnoses being managed and the overall progress of the patient.
Advantages and Disadvantages
The major advantage of the SOAP documentation format is it's widespread adoption, leading to general familiarity with the concept within the field of healthcare. It also emphasizes clear and well-organized documentation of findings with a natural progression from collection of relevant information to the assessment to the plan on how to proceed.
However, the format has also been accused of encouraging documentation that is too concise, overuse of abbreviations and acronyms and that it is sometimes difficult for non-professionals to decipher. DeVito and Snyder-Meckler (1995) have also suggested that a sequential, rather than integrative approach to clinical reasoning is encouraged, as there is tendency by the health professional to merely collect information and not assess it. They feel that the emphasis on the problem-orientated approach to documentation is misplaced and that it is not conducive to clinical decision-making.
One major difficulty with SOAP notes for physiotherapists is the lack of guidance on how to address functional outcomes or goals. Having said that, the format is not so rigid that it cannot be adapted to take this into account.
In conclusion, a SOAP Notes are short documents that shows current, past and continuous regimen of a patient. These notes will stay within a patients’ medical history for future reference. Moreover, they are easy to interpret into a computer. If well written and it is organized then you will be able to present your case within a few minutes. SOAP Notes are easy once you get the hang of them. So don’t stress as they will become habitual in your day to day workings.