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5 Perfect Nursing SOAP Note Examples + How to Write
Written By: Darby Faubion, RN, BSN, MBA
One of the most important parts of a nurse’s job is documentation, and there are several types of nurses' notes used in nursing care today. Nursing notes are the way healthcare providers communicate and promote continuity of care.
In this article, we will discuss one type of nursing notes, SOAP nursing notes. I will answer the question, “What is a nursing SOAP note?” I will also share the steps to writing a good SOAP nursing note and provide you with 5 perfect nursing SOAP note examples + how to write them.
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WHAT IS A NURSING SOAP NOTE?
SOAP nursing notes are a type of patient progress note or nurse’s note. It is the documentation used to record information about encounters with patients that follows a specific format. SOAP notes include four elements: Subjective Data, Objective Data, Assessment Data, and a Plan of Care. This type of nurses’ note is used by nurses and other healthcare providers to create a record of patient progress from the time of admission to discharge. The notes include subjective information gathered from the patient or caregivers, objective data, your assessment/diagnosis, and a plan based on all the data gathered.
WHO DEVELOPED NURSING SOAP NOTES?
Nursing SOAP notes were first introduced in the 1960s by Dr. Lawrence Weed
. At that time, there was no standardized process for nursing or medical documentation. Originally, SOAP nursing notes were part of what is known as the Problem-Oriented Medical Record (POMR). Each note identified one problem or diagnosis identified by the primary physician forming only one part of the documentation record. Various disciplines, including nurses, began using the SOAP format to document nursing notes. Today, the POMR and SOAP notes are considered separate types of documentation.
WHAT IS THE PURPOSE OF WRITING A NURSING SOAP NOTE?
The primary purpose of a nursing SOAP note is to allow clinicians to document patient encounters in a continuous, structured way. These notes help healthcare teams track patient progress by maintaining a record of symptoms, care, and response to treatment. They provide an easy way to track test results, vital signs, patient status changes, and treatment plan updates in one place where all providers have access.
WHAT IS THE DIFFERENCE BETWEEN A NURSING SOAP NOTE AND A NURSING PROGRESS NOTE?
The terms nursing SOAP note and nursing progress note are often used interchangeably. However, there are some differences. Progress notes are typically used on the initial patient contact, and they include histories, physicals, and SOAP notes. SOAP nursing notes follow the subjective, objective, assessment, and planning format, allowing nurses to document continuing patient encounters using a structured format.
Nursing progress notes typically have one field called a “free text” field where you will write narratively about your encounter with the patient. The SOAP note is formatted with individual sections for recording subjective, objective, assessment, and planning data and information.
4 ADVANTAGES OF NURSING SOAP NOTES
There are many types of nursing notes, and each has advantages and disadvantages. The type of note you use is usually determined by the facility where you work. The following are four advantages of using SOAP nursing notes.
ADVANTAGE #1: Nursing SOAP notes facilitate clinical reasoning.
The format used for SOAP notes prompts the nurse to review all evidence, including subjective and objective data and information from the assessment, before reaching a nursing diagnosis. This is essential because if the nurse considers all the subjective and objective data while performing an assessment, they can develop a care plan based on the patient's individual needs. Individualized care is essential in improving patient outcomes.
ADVANTAGE #2: SOAP Nursing notes promote active listening.
Active listening involves more than hearing with your ears. It also involves hearing what the patient does not say verbally but reveals through nonverbal communication, such as body language and behavior. Because SOAP notes include the element of subjective data, nurses must be intentional about actively listening to patients. Active listening
helps foster a more trusting relationship between nurses and patients, which is crucial in providing timely, appropriate care.
ADVANTAGE #3: SOAP nursing notes help create a detailed medical history.
Another benefit of using nursing SOAP notes is that they allow you to create a problem-oriented record that all members of the interdisciplinary team can use. When we write nursing notes focused on the patient’s complaints, we create a timeline of symptoms and a record of the patient’s response to interventions, which is crucial in determining expected outcomes.
ADVANTAGE #4: Nursing SOAP notes help facilitate communication between nurses and doctors.
Although doctors and nurse practitioners make clinical diagnoses, that does not mean that the nurse’s assessment and findings are irrelevant. In fact, the contrary is true, and SOAP nursing notes are one way nurses can communicate their findings to doctors, even if they are not face to face. When used correctly, SOAP notes tell the patient’s story from the onset of symptoms to discharge. Having this type of information at their fingertips makes it easier for doctors to diagnose and treat patients and the interdisciplinary team to communicate effectively.
3 DISADVANTAGES OF NURSING SOAP NOTES
Although the use of nursing SOAP notes has several advantages, some practitioners feel there are disadvantages to this type of documentation. The following are three of the main disadvantages associated with using SOAP nursing notes.
DISADVANTAGE #1: Many nurses and healthcare providers question the order of the SOAP nursing note format.
Many nurses feel the order of the SOAP format should be changed to APSO. Although the same information is gathered, assessing the patient and creating a plan based on your assessment, then following with subjective and objective data seems to make it easier for nurses and other healthcare providers to navigate the patient's chart and find pertinent data. The idea behind this thought process is that healthcare workers can acquaint themselves with the client’s present health status and current plan and then determine if changes in the plan are indicated based on subjective and objective findings.
DISADVANTAGE #2: Patients may have several complaints that must be addressed.
Although patients may have several symptoms or complaints, the nursing SOAP note is designed to address one chief complaint. That does not mean other symptoms or concerns are not documented, but they are listed in order of priority, with the plan of care following that list of priorities. As one complaint or issue is improved or resolved, the focus on the SOAP note may change, which can be confusing. This is especially true in hospital settings where nurses work various shifts, and several clinicians may care for a patient during their hospital stay.
DISADVANTAGE #3: Gathering information to determine patient progress can be time-consuming with SOAP nursing notes.
One of the main disadvantages of nursing SOAP notes is that it is challenging to process updates in data over an extended period. Providers must comb through patient charts containing several encounters and SOAP nursing notes before deciphering the effectiveness of treatment and determining whether a new treatment plan is indicated. The time it takes to go through this type of record, many clinicians feel, could be better spent providing direct patient care and assessments.
WHAT ELEMENTS SHOULD BE INCLUDED IN A NURSING SOAP NOTE?
Nursing SOAP notes consist of four elements, subjective data, objective data, your assessment, and the plan of care. Each component of the note should be well-written and address only information relevant to the patient’s immediate concerns or complaints.
1. Subjective Data (S): Subjective data
is any information gathered directly from the patient. This element of the SOAP nursing note includes your patient’s description of their health history and current symptoms. Subjective data also includes any elements of the patient’s family, social, and medical history. The patient is the best source of information about their health. Therefore, gathering subjective data is essential in making an appropriate diagnosis and developing an effective care plan.
2. Objective Data (O):
Objective data is any information relevant to the patient’s condition that can be measured or observed. Vital signs, diagnostic test results, and the patient’s age are examples of objective data. Objective data is essential in preparing accurate SOAP nursing notes because it reflects things patients may or may not know. For example, the patient may know that his head hurts, which is subjective, but he may not realize that his blood pressure is elevated, which is objective until the nurse measures his blood pressure.
3. Assessment Findings (A):
The assessment part of nursing SOAP notes combines subjective and objective information, which is used to form a diagnosis.
4. Plan of Care (P):
The last step in preparing a SOAP nursing note is to establish and document a treatment plan designed to address the diagnosis formed from the assessment. The part of the note that explains the plan may include orders for further testing, patient education, referrals to specialists, or support services, such as home health or hospice.
WHAT ELEMENTS SHOULD NOT BE INCLUDED IN A NURSING SOAP NOTE?
Creating thorough nursing SOAP notes requires following the proper format and utilizing pertinent information related to the patient's condition. One of the things I used to struggle with when preparing SOAP notes was that my love of writing often made my notes look more like long narrative notes instead of formulated SOAP nursing notes. When writing these notes, keeping content specific and relevant to the patient's current complaint or condition is essential. There are a few elements that should be excluded from nursing SOAP notes, including the following.
1. Information that Is Irrelevant to the Patient’s Current Condition:
The SOAP nursing note should address issues the patient is currently experiencing. Irrelevant information or information unrelated to the current complaints, symptoms, or treatment plan should be avoided.
2. Speculations About the Patient’s Symptoms or Feelings:
Your job when writing SOAP nursing notes is to document the facts as they are presented by the patient, caregiver, or objective data. Speculating about what a patient is thinking or feeling should be avoided. Instead, pay attention to what your patient says and how he acts, and document what you see and hear.
3. Confusing Pronouns:
When documenting in a SOAP nursing note, be careful to use appropriate titles and names instead of confusing pronouns. For instance, instead of writing, "She instructed the client to state her name," you should write, "Clinician asked the client to state her full name, and pt was able to do so."
4. Avoid Judgmental Statements:
As you interview patients and caregivers, there may be times when the source of information tells you something that you feel is inaccurate or inappropriate. It is your job to document findings accurately and nonjudgmentally, even if you feel sure the information they provide is incorrect.
For example, if you have a pediatric patient whose mother states the child began walking at five months of age, instead of writing, “The pt’s mother is obviously mistaken because she says he started walking at five months of age," you should write, "Pt.'s mother reports pt. took first steps at approximately five months of age.”
5. Avoid Using Slang Terms or Unprofessional Phrases:
When writing SOAP nursing notes, your statements should reflect a professional voice and avoid slang terms or phrases. Imagine caring for a patient who is beginning to ambulate with assistance after surgery. Instead of writing, “Pt. walked in hallway and had an awesome time,” it is more appropriate to write, "Pt. ambulatory in the hall with minimal assistance; displayed a cheerful effect and tolerated the walk well."
HOW TO WRITE A PERFECT NURSING SOAP NOTE?
(The following is a step-by-step process to write a perfect nursing SOAP note.)
Creating the perfect SOAP nursing note involves four main steps, each of which has small objectives. You must gather subjective data and objective data, perform a nursing assessment, and create a nursing care plan. After the four SOAP steps are complete, you will then craft your note. Below you will find the main categories for the steps and a breakdown of each one.
GATHERING SUBJECTIVE DATA
STEP #1: Interview the PatientThe first step in writing a SOAP nursing note is to talk with your patient. This is when you gather subjective data. In this step, your goal is to find out what the patient is experiencing from their point of view. Do they feel pain? How bad would they rate their pain? Are they short of breath? Do they have decreased appetite? Anything the patient feels and experiences is subjective and should be recorded.
STEP #2: Use the Mnemonic Device OLDCARTSWhen writing a SOAP nursing note, using the acronym OLDCARTS is an excellent way to remember what to ask your patient about symptoms during the interview.
• O- Onset: When did the chief complaint begin?
• L- Location: What part of the body is affected?
• D- Duration: How long have these symptoms been present?
• C- Characterization: Can you describe the pain? (Dull, sharp, aching, throbbing, etc.)
• A- Aggravating or Alleviating Factors: Does anything make the symptoms better or worse?
• R- Radiation? Does the symptom move from one area of the body to another?
• T- Temporal patterns: Does the symptom occur at specific times?
• S- Severity: How would you rate your pain on a scale of 1 to 10?
STEP #3: Collect the Patient’s Personal and Family Medical HistoryAsk the patient if they have a history of medical problems or surgeries. Gather as much information as possible, including the date of any diagnoses or surgeries, and the doctor(s) who treated them. Ask if there is a family history of health conditions similar to what the patient is experiencing. Keep in mind that you only need family history relevant to your patient's current issues, not an entire family medical history.
STEP #4: Verify Medications and Allergies, If ApplicableYou need to know all medications the patient is taking, including over-the-counter medications and supplements. Record the name, dosage, and frequency of how often the medication has been taken since the onset of symptoms. For example, “APAP 500mg tid X 2days.”
GATHER OBJECTIVE DATA
STEP #5: Measure the Patient’s Vital SignsAfter gathering subjective data, you move on to collect objective data, beginning with vital signs. If the patient's blood pressure, pulse, or respiration are out of normal limits, double-check them to verify accuracy and document they were checked twice. For instance, "Blood pressure 180/96 in right arm. Repeat blood pressure in left arm 182/94." It is crucial that you verify abnormal findings or inconsistencies because care plans and interventions are based on the findings of your assessment.
STEP #6: Document Objective Findings In this step of the SOAP nursing note, it is essential to document your findings, not subjective reports. For example, instead of "Patient reports right knee pain," you would write "Tenderness noted when pressure is applied to the right knee. Redness and bruising also noted on visual inspection."
STEP #7: Update Test ResultsCheck for any new laboratory or diagnostic test results and update them in your note. In some cases, if EHRs are used, you may only need to reconcile the electronic document to make sure the results uploaded to the patient’s chart. If you still use paper charts, you should document findings and attach a copy of the test results.
PERFORM AN ASSESSMENT
STEP #8: Observe the Patient for Any Changes Since the Last AssessmentReview the patient’s chart to determine if there is a previous SOAP nursing note. If you are not the first nurse to care for the patient, you want to know what the former nurse observed and documented and observe the patient for any changes since the last assessment. Look for changes in the patient’s level of consciousness, orientation, pain, or response to treatments.
STEP #9: List Patient Complaints Based on Order of PriorityYour SOAP nursing note should focus on the patient's complaints in the order of priority or severity. If the patient has several complaints and you are unsure which symptom or problem is worse, ask them to rate their symptoms and what they are most concerned about. Look at the subjective and objective data in your note to determine the most probable cause of your patient's problem, then list the problems according to the order of priority.
STEP #10: Form a Nursing DiagnosisForming a nursing diagnosis is one of the essential steps in the nursing process. If there is a clear diagnosis for the patient’s problem, it should be listed immediately after the problem in your note. You can determine a nursing diagnosis based on subjective and objective data. For instance, if your patient has a history of diabetes mellitus and presents with elevated blood glucose, polyuria, polydipsia and reports being "out of sugar medicines," your diagnosis may be Risk for Unstable Blood Glucose Levels R/T insufficient DM management or medication compliance.
STEP #11: List the Rationale for the Nursing Diagnosis You ChooseAfter forming a diagnosis, you should cite reasons for choosing that diagnosis based on subjective and objective data.
CREATE A PLAN
STEP #12: List Any Nursing Interventions Which Must Be ImplementedEach diagnosis should be followed by a list of interventions relevant to that specific diagnosis. For example, if your patient has uncontrolled Diabetes, as in the example above, appropriate interventions would include the following:
• Perform FSBS ac and hs
• Educate patient on medication compliance
• Refer to nutritionist for diabetic meal planning
WRITE YOUR NOTE
Step #13: Record Pertinent Patient InformationYour note should begin with the patient’s name, age, sex, and chief complaint. For example, you may write, “54 y/o male presenting to clinic with abdominal pain.”
Step #14: Organize Information in the Note According to the SOAP FormatThe way your SOAP nursing note is structured will be determined by your healthcare facility. Some facilities prefer bulleted formats, while others prefer paragraphs under each subheading. Be sure to add all relevant information under the appropriate subheading. On subsequent patient encounters, document any changes from the previous encounter.
WHAT ARE THE PERFECT EXAMPLES OF NURSING SOAP NOTES?
(Below are 5 perfect nursing SOAP note examples.)
NURSING SOAP NOTE EXAMPLE #1: Patient with Chest Pain and Shortness of Breath
Subjective: Mr. Jones is a 71 y/o white male who presented to the ER yesterday at 0800 with intermittent chest pain and S.O.B. Pt. Reports pain has lasted off and on for the last six hours. He has a personal history of HTN, high cholesterol, and Type I DM. Family history positive for heart attacks, HTN, and Diabetes. After a 12-lead EKG, lab draw, and chest CT, pt. was diagnosed with transient angina. After being treated and stabilized in the ER, pt. was transferred to cardiac care for observation. Pt continues to complain of S.O.B. with ambulation but denies chest pain currently. No known allergies. Medication list provided and chart updated.
Objective: Pt is A & O x4, pulses + x4 extremities. BP 146/90, R 24, HR 88, T 98.4, SpO2 92%. Lungs CTAB, HR regular. Skin is pale, warm, and dry, with slight cyanosis noted around lips. Pt walked from room to nurse’s desk with some S.O.B. noted on exertion.
Assessment: Activity intolerance as evidenced by decreased SpO2, elevated respiratory rate, and cyanosis of lips.
Plan: Apply O2 per NC @ 2L continuously, elevate HOB at least 45 degrees, encourage deep breathing exercises, continue to monitor vital signs and patient complaints, call light in place with instructions to call for assistance.
NURSING SOAP NOTE EXAMPLE #2: Patient with Productive Cough and Fever
Subjective: Patient M.S. presented to the clinic with c/o persistent productive cough x5 days. She reports symptoms were first “like a cold,” but have progressively worsened in the last 48 hours. Use of OTC cough suppressant is minimally helpful. C/O some tightness in chest and difficulty taking deep breaths. Reports fever of 101.6 before coming to the clinic. Denies chills. Sputum is thick, mostly white, with a yellow tinge. No hemoptysis. Reports yellow nasal mucous when she blows her nose and facial tenderness.
Denies history of chronic pulmonary health issues but reports she is a smoker of 1 PPD x 20 years. Type 2 Diabetes is well-controlled on Ozempic 1 mg./weekly. Takes ASA 81mg qd prophylactically. No other prescripts or OTC medications. No significant personal or family medical history. No known drug or food allergies.
Objective: Skin is pink, warm, and dry. Slight dyspnea on exertion noted when ambulating from bed to restroom. Vital Signs: B/P 120/78, P 84, R 26, T 100.2. Lungs CTAB. HR is steady, no murmurs, normal S1 and S2. No edema, pulses present x4 extremities. CXR negative for effusion or pneumonia. Heart is normal in size. Sinus x-ray series shows soft-tissue density causing sinus cavity expansion.
Assessment: Recent onset of productive cough, purulent nasal drainage, facial tenderness, and low-grade temperature. CXR negative for pneumonia, no edema suggests the absence of CHF.
Plan: Treat with albuterol inhaler 2 puffs q6hrs and Amoxicillin 500 mg. bid, as per MD orders. Instructed patient on the appropriate use of inhaler and coughing and deep breathing exercises; educated on smoking-related risks and encouraged smoking cessation; Instructed pt to follow up in clinic if no improvement and to go to ER with new or worsening symptoms.
NURSING SOAP NOTE EXAMPLE #3: Patient with Skin Outbreak
Subjective: Patient V.H. is a 60 y/o black male who presented to the urgent care clinic with c/o rash lasting >1 wk. He reports the rash first appeared on his lower back toward the spine but has since spread to the abdomen on his right side. Denies experiencing pain when the rash first appeared but now feels pain described as a "burning sensation." He reports increased pain when clothing touches the affected area and, therefore, does not wear a shirt at home. V.H. has been taking APAP 500 mg. q4-6 hours for pain with little relief. He currently rates pain as a 6 on a 1-10 scale.
History of HTN and BLE edema. Takes Metoprolol 50 mg. BID and Lasix 20 mg q am.
Objective: V.H. is A&O x4 and appears in no acute distress, despite reports of pain. VS: BP 126/78, P 70, R 14, T 98.6 SaO2 98%; Erythematous rash consisting of clustered vesicles beginning on the right lateral spine area and extending around the right flank and abdomen. Some vesicles are fluid-filled, and others are covered with a honey-colored crust.
Assessment: Onset of painful rash beginning 1 wk. ago with right lateral distribution. The presence of erythematous, fluid-filled vesicles and honey-colored crusts, distribution, and burning pain suggests herpes zoster. Although cellulitis may be possible, the absence of fever suggests otherwise.
Plan: Pt. Will continue using APAP for pain relief, educated patient that symptoms may continue after the rash resolves but that once all lesions have developed crusts, he is no longer contagious. V.H. will return to clinic if pain worsens, fever develops, or lesions do not resolve within 4 weeks. Instructed on importance of keeping open or draining sores loosely covered and to leave scabs and blisters undisturbed.
NURSING SOAP NOTE EXAMPLE #4: Clinic Follow-Up- Diabetes Patient
Subjective: Ms. H. is a 49 y/o woman here for f/u appt for management of Type 1 DM. Last clinic visit was 6 months ago at which time her A1C was 6.5 Pt. did not reach A1C goal on Metformin. Currently takes Mounjaro 5 mg. once weekly. Pt reports FSBS ranging between 70 and 100 daily. She denies polydipsia, polyphagia, and polyuria. Ms. H. reports she works a full-time job and often eats on the run but is trying to make more healthy food choices.
History of hyperlipidemia, with last lab work showing LDL of 194.
Other medications include Zoloft 50 mg qd, Folic Acid 2 mg qd, and Simvastatin 20 mg qd.
Objective: Pleasant affect, alert and oriented x4, no complaints voiced, no acute distress noted. Vital Signs: BP 130/80, P 68, R 18, T 98.1. Repeat HgB A1C performed yesterday with result of 5.4, which is lower than the most recent A1C drawn six months ago. CBC within normal limits, CMP reflects the following: Glucose 78, creatinine 1 mg, potassium 4.5, all of which were elevated on previous lab results. Lipid panel this visit reflects LDL 125. All other labs remain WNL.
Skin is warm, dry, and intact. No signs of compromised skin integrity. Diabetic foot assessment performed and was unremarkable.
Assessment: This is a follow-up visit for continuing care of Type 1 Diabetes Mellitus. Pt. continues to have blood glucose levels per FSBS within normal limits and checks her levels twice daily. Hyperlipidemia and DM are well controlled with diet and medication as evidenced by lab work and patient report.
Plan: Pt. Will continue meds as prescribed and daily FSBS. Repeat A1C and Lipid Panel in 6 months. Pt. to return to clinic with new onset of symptoms or concerns. Per pt.'s request, referral to nutritionist was given to assist with meal prep ideas within dietary restrictions for Diabetes and Hyperlipidemia.
NURSING SOAP NOTE EXAMPLE #5: Patient with History of Congestive Heart Failure
Subjective: Patient G.P. is a 64 y/o male who presented to the ED with complaints of S.O.B. when resting and swelling of both feet and legs. He arrived at the ED by private vehicle accompanied by his spouse. Pt reports swelling in feet and legs began about "five or six days ago" and that S.O.B. "never goes away."
Pt has a history of CHF and is admittedly non-compliant with medication regimen. He has a prescription for Lasix 40 mg. qd but states, “It’s been a while since I took it” and indicates the constant need to use the restroom makes him not want to take his medication. Pt. also has an order for 02 per NC @ 2L continuous but also reports smoking at least ½ PPD of cigarettes. His wife reports the swelling in his legs has gotten progressively worse in the last several weeks, and his cough is also worse. Pt. reports his cough is productive with thick, yellow sputum. Denies pain, fever, aches, vomiting, or diarrhea. No other complaints voiced.
Past medical hx: CHF, HTN, Atrial Fib; no surgeries; last hospitalization 11 months ago for exacerbation of CHF at which time pt left the hospital AMA. Current medications: Lasix 40 mg qd (not taking), Lopressor 25 mg BID, Losartan 50 mg qd. Smokes ½ to 1 PPD cigarettes x 25 yrs. Denies the use of alcohol or illegal drugs.
Family medical hx: Paternal HTN, MI, and CVA, Father died from complications of MI; Mother: Breast CA, DM, HTN.
Objective: Pt. is an A&O male who appears mildly agitated; skin is pale and clammy. Vital Signs: B/P 160/94, P 82, R 24, T 98.3, Sp02 92%. Weight today is 249 lbs. Pt reports he weighed at home two days ago and weighed 243 lbs. Bowel sounds active x4, abdomen nontender. Bilateral lung bases positive for crackles; no retraction, symmetrical rise and fall of the chest. Pulses present X 2 upper & lower extremities. 3+ pitting edema in bilateral lower extremities.
12-Lead EKG shows Atrial Fibrillation, CXR shows cardiomegaly but no acute cardiopulmonary abnormality; CBC and CMP today WNL.
Assessment: Based on orthopnea, S.O.B. with minimal exertion, BLE edema, weakness, and fatigue, pt. is likely experiencing an acute exacerbation of CHF. S.O.B. and hx of smoking could be indicative of COPD. However, BLE edema suggests the more appropriate diagnosis is CHF.
Plan: Pt. admitted to telemetry for O2 support, evaluate for diuresis r/t fluid overload, and cardiac workup. Echocardiogram and stress test ordered for tomorrow a.m. Continue home meds except for Lasix po. Start Lasix 40 mg IV twice daily; Monitor I & O; Educated patient on importance of medication compliance and the risk to cardiovascular and pulmonary health from smoking. Pt agrees to try nicotine patch to “see if it works.”
5 MOST COMMON MISTAKES TO AVOID WHILE WRITING NURSING SOAP NOTES
When writing nursing SOAP notes, it is essential to follow the format carefully. Some of the most common mistakes nurses make when writing these notes are easily avoidable. The following are five of the most common mistakes made when writing SOAP nursing notes and how to avoid them.
MISTAKE #1: Not Naming the Source of Information
About the Mistake:
When writing a SOAP nursing note, it is essential to state the source of any information you record in the note. Referencing the source of any data you gather will help paint a more clear picture of the patient’s status and shed light on who is available and involved in their care.
How to Avoid:
The best way to avoid this mistake is to document exactly what you are told and by whom. For example, if the patient reports feeling nauseated for the last two days, you will write, "Pt. reports nausea X2 days." If your patient's spouse tells you she seems confused lately, document by saying, "Pt.'s spouse is present and reports pt. seems confused at times," and give examples.
MISTAKE #2: Not Providing Supporting Objective Data
About the Mistake:
The objective data section of the SOAP nursing note is where you document your observation of the patient. This section should include interventions and patient responses to them. It should also include measurable outcomes related to your patient such as test results, the percentage of completed goals, and all other quantitative data.
How to Avoid:
You can avoid this mistake by avoiding general statements that lack supporting data. For instance, if you asked the patient to perform a task, instead of saying, "Pt. Responds well to verbal cues," you could say, "Pt. responds to verbal cues by following directions for opening utensils and using appropriate utensils. Pt. also responded appropriately to questions about his preferred meal stating he would rather ham instead of turkey.”
MISTAKE #3: Repeating Subjective and Objective Data in the Assessment Section
About the Mistake:
The nursing SOAP note is designed to follow a set format, and when followed correctly, information does not become repetitive. The assessment section should be used to describe your analysis of the patient’s progress, laboratory and diagnostic test results, and any new or worsening symptoms.
How to Avoid:
Instead of rewriting what is in the subjective and objective section, take a few moments to review the information and review your patient’s progress toward goals or regression in status. Assess factors that contribute to these changes and document them.
MISTAKE #4: Rewriting the Whole Treatment Plan
About the Mistake:
As nurses, we know the importance of thorough documentation. There is a difference in being thorough and being repetitive, however. When writing a nursing SOAP note, the plan section of the note should not repeat information that has already been recorded.
How to Avoid:
Instead of rewriting the treatment plan, use this section of the note to create an outline of the next steps in patient care. Your next steps should be based upon the findings of your most recent assessment. For example, if your patient is responding well to treatment and reaching goals, you may document and say, “Pt. response to current treatment plan effective; continue current plan and reevaluate progress.” On the other hand, if your patient is not responding well to the current treatment plan, this is the place at which you will create new goals and objectives.
MISTAKE #5: Assuming the First Complaint is the “Chief” Complaint
About the Mistake:
When writing a SOAP nursing note, the first step is to record subjective data. The information in this section lays the foundation and sets the context for later sections. When patients report several symptoms, there is typically one major or chief complaint.
How to Avoid:
Although patients may report several symptoms or complaints, it is the nurse’s responsibility to gather as much information as possible and try to determine the primary cause of the patient’s complaints. Finding the primary complaint is the most critical step in completing a SOAP nursing note because all other sections of the note should build upon the subjective data you collect.
BONUS! 5 EXPERT TIPS FOR WRITING NURSING SOAP NOTES FASTER
When it comes to nursing documentation, we all want to save time. However, it is crucial that saving time does not come at the cost of poor performance on our part. There are a few things you can do to help write nursing SOAP notes faster and more efficiently. The following are a few expert tips I suggest to help you.
TIP #1: Write your note at an appropriate time.
The first step in writing nursing SOAP notes in less time is to find the right time, free of distractions, to write your note. Avoid writing the note while you are in the room with the patient. Instead, take a pen and paper with you to jot down important information while interviewing and assessing your patient. Then, write the note when your assessment is complete, and you have left the patient’s room. Keep in mind that your note should be written as soon as possible after your patient session has ended so you do not forget important information.
TIP #2: Use direct statements, avoiding overly wordy content.
Your nursing SOAP note should be clear and concise, providing direct insight into what the patient is experiencing without embellishments.
For example, avoid writing a statement like this: “This nurse has made careful consideration of the patient’s status and concludes he responds well to verbal cues and articulates his feelings appropriately, stating he feels fine.”
Instead, you may write, “Pt. responds well to verbal cues, voices no complaints upon assessment.”
TIP #3: Be specific and to the point.
The format for SOAP nursing notes is simple, which makes it easier to get to the point. Document only pertinent information and do so without personal opinions or embellishments. Keeping your note specific and to the point will help other practitioners follow the patient’s progress without having to weed through unnecessary information.
TIP #4: Document each patient encounter as soon as possible.
If you document patient encounters when they occur instead of waiting until the end of your shift, you can save time. Conversely, waiting until a later time to document in your SOAP nursing note increases the chance of forgetting important information, which could make you have to return to the patient’s room to gather data.
TIP #5: Connect interventions with your diagnosis.
From a nursing management perspective, it is crucial for nurses to document about patient care with reimbursement for services in mind. One thing I have always told nursing students is, “If you did not document it, you did not do it.” That may seem harsh or a little over the top, but in the eyes of the law, documentation is the only proof you have that you provided care. In the eyes of insurance companies and other pay sources, documentation is your proof that services were provided, and payment is due. If you write your nursing SOAP note with reimbursement in mind, you do not have to go back later and try to connect the dots to make sure the patient can be billed.
MY FINAL THOUGHTS
With so many types of nursing notes available, it is normal to wonder, “What is a nursing SOAP note?” In this article, I shared information about what a SOAP nursing note is, the elements included in the notes and 5 perfect nursing SOAP note examples + how to write them. As a nurse, I encourage you to follow your facility’s protocol for nursing documentation carefully and to remember, if you did not chart it, you did not do it!
FREQUENTLY ASKED QUESTIONS ANSWERED BY OUR EXPERT
1. Who Can Write A Nursing SOAP Note?
Nurses, nursing students, and other healthcare providers can write nursing SOAP notes.
2. When To Write A Nursing SOAP Note?
You should write a nursing SOAP note anytime there is a need to document your patient’s progress. The frequency of notes will depend upon how often the patient is seen/assessed.
3. Do Nurses Write SOAP Notes Every Shift?
In facilities where SOAP nursing notes are used, nurses typically write a SOAP note at least once each shift.
4. Ideally, How Long Should Nursing SOAP Notes Be?
Most SOAP nursing notes are one to two pages long for each patient encounter. Each section may have one to two paragraphs.
5. What’s The Most Important Part Of A Nursing SOAP Note?
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. Therefore, all parts of a nursing SOAP note are equally important.
6. Can I Use Abbreviations In A Nursing SOAP Note?
Yes, you may use abbreviations in a nursing SOAP note for medical terms. However, it is best to use complete words when possible. If you are unsure of how to correctly use an abbreviation, it is always best to err on the side of caution and spell out the words.
7. What Tense Do I Write A Nursing SOAP Note?
Because nursing SOAP notes are written with each patient encounter, they should be written in present tense.
8. Are Nursing SOAP Notes Handwritten Or Printed?
If you work in a facility that does not use Electronic Health Records, you may need to manually write your notes. Nursing SOAP notes may be handwritten in cursive or print. The most important thing is to ensure your note is legible.
9. How To Sign Off 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 The Time It Should Have Been Written?
Failure to write a SOAP nursing note at the time it should have been written can have negative consequences for nurses, healthcare teams, and their patients. If you forget to write a note and have already left work, call your nursing supervisor immediately and report the oversite and any important patient information. Upon returning to work, you should complete your note by recording the date of the events and any information necessary, and document that the entry 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 a nursing SOAP note. It is customary for the nursing instructor to sign behind the student at the end of the note.
Darby Faubion, RN, BSN, MBA
Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX).