nursing soap note

Nursing Soap Note Writing Guide

Nursing Soap Note Writing Guide

Are you stuck on a nursing SOAP Note writing assignment? Relax! Writing SOAP Notes can be difficult, especially if this is your first time. Our experts have created a step-by-step guide based on the experience of our top nursing writers.

To understand the meaning of the acronym, we begin by defining SOAP Notes. Next, the guide explains the importance of SOAP Notes before diving into the structure and anatomy of soap notes.

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We have created templates for SOAP notes to support counseling, coaching, and clinical practice because we are experts in writing guides for students.

We also included abbreviations you can use as well as tips to help with writing a better SOAP Note. No matter what type of situation it may be, it doesn’t matter. This guide will help you if you have the correct instructions.

Our nursing assignment assistance website also offers SOAP note assignments to students. Our SOAP notes can be used as a benchmark or reference when you write yours. You can order this product by visiting our homepage or clicking on the Order Now button.

What is a Nursing Soap Note and how does it work?

The acronym SOAP stands to begin. It stands for Subjective Objective, Assessment and Planning.

According to Podder et.al. (2020), The Subjective, Objective and Assessment (SOAP) note is a common method of documentation by healthcare providers. It is also used by healthcare workers to organize and document patient information/records in a structured manner.

SOAP notes help healthcare workers use the clinical reasoning cycle to diagnose, treat, and assess patients using objective and subjective information. They make it easier for health professionals to communicate with one another, making inter- and intra-professional communication easier.

SOAP notes form part of a patient’s medical record. They must be clear, concise, and thorough.

Dr. Lawrence Weed was the father of SOAP Notes and a University of Vermont student. SOAP notes are an ancient practice dating back to the 1960s.

Let’s look at how to create a SOAP note. The simple, four-part medical component is what gives many students headaches.

Structure/Anatomy a Clinical SOAP Note

We now know what the SOAP Notes do, let’s look at the structure of a SOAP Note step-by-step.

S = Subjective

Subjective assessment refers the information provided by patients. This helps to determine the problem.

This means the content is derived from the personal experiences, views or feelings of the patient or a close friend.

This section provides context for the SOAP note’s assessment and plans sections.

Interim information is required for patients in the hospital setting.

It is often in narration form.

Chief Complaint. (CC)

The patient reports the CC (or presenting problem). The patient can report a symptom or a condition.

The CC is similar in appearance to the title of a paper. It allows the reader to see the contents of the remainder of the document.

  • Examples include chest pain, sore throat and decreased appetite.

A patient might have several CC’s and the first may not be the most important. Physicians should encourage patients to list all of their problems and pay attention to details to find the most pressing problem.

To perform an efficient and effective diagnosis, it is important to identify the root cause of the problem.

History and Present Illness (HPI).

The HPI starts with a one-line opening statement that includes the patient’s age, gender, and the reason for their visit.

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

This section is where patients can discuss their main complaint. OLDCARTS is an acronym that is used to organize the HPI.

  • Inception: What year did the CC start?
  • Where is the CC?
  • Duration – How long has this CC been in operation?
  • Characterization  How can the patient describe the CC
  • Allergating and aggravating factors – What makes the CC more powerful? Worse?
  • Radiation  Can the CC move to another location or remain in the same place?
  • Temporal element: Does the CC perform worse or better at certain times of the day?
  • Severity How does the patient rate the CC on a scale from 1-10?

Clinicians should not be too specific in their notes. Instead, they should focus on quality and clarity.

History

  • Past or current medical conditions
  • Surgical History : Include the year and name of the surgeon, if possible.
  • Family History : Add relevant family history. Do not document the medical history for every member of the patient’s immediate family.
  • Social History : HEADSS is an acronym that can be used to refer to Home and Environment, Education, Employment, Eating, Activities, Drugs, Sexuality, and Suicide/Depression.

Allergies, Current Medications

You can list current medications and allergies under the Objective or Subjective sections. Any medication must be documented. This includes the name of the medication, dosage, route and how often it is taken.

  • Example: Ibuprofen 25mg orally every 4-6 hours for 2-3 days

O – Objective

This section of your SOAP note should contain objective data about the patient encounter.

  • General Survey
  • Vital signs
  • Range of Motion (ROM: See a detailed explanation down below.
  • Latest Labs with date of draw, EKG/UA/any other diagnostics that pt brought recently.
  • Circulation
  • Lymph
  • Abdominal
  • Palpation -Soft and bony
  • Results of a physical exam
  • Labor data
  • Images
  • Additional diagnostic data
  • Special Offers
  • HEENT
  • Recognize and review the documentation of other physicians.

Review of Systems

This system-based list of questions helps uncover symptoms that may not have been mentioned by the patient.

  • General Survey: Weight loss and decreased appetite.
  • Gastrointestinal: Abdominal pain, hematochezia
  • Musculoskeletal Toe pain, reduced right shoulder range

Students make the common error of not distinguishing symptoms from signs when they write the SOAP note objectives section.

Symptoms should be described by the patient and documented under the subjective heading. A sign is an objective finding that is related to the associated symptoms.

A patient may say they have stomach pain. This is a subjective symptom. However, abdominal tenderness to palpation is an objective sign.

This section should be written:

  • Avoid general intervention
  • All the special tests are noted
  • You must identify the injury to be able to see the root problem.
  • Make sure to include enough information
  • Make sure you are clear, concise, and easily understandable

A: Assessment

Your SOAP note’s objective and subjective components form the assessment section. This is your working diagnosis. This means you combine the objective and subjective evidence to reach a diagnosis.

The section involves assessing the patient’s condition through analysis of the problem and possible interactions of the problems. It also includes changes in the status or the possibility of problems.

The section is updated during follow-up visits to reflect changes in Subjective or Objective as a result of time, treatment, or other interim events.

It is updated in practice to reflect the current condition of the patient. The patient’s current condition can be included in the section.

Its major components include:

Primary Problem/Diagnosis/Working Diagnosis

You should order the problems according to importance. In this instance, the problem is the diagnosis.

The primary diagnosis must be listed first. Next, you should list 2-3 differential diagnoses. Make sure you include the ICD-10 code to diagnose the condition.

Differential Diagnosis

This section is where you list all possible diagnoses. This section explains the decision-making process in detail.

When listing the differential diagnosis, explain why it is one. Cite from journals and other scholarly sources.

Also, for every diagnosis, please cite the exact reasons that are based on the Objective and Subjective sections of the Soap Notes

P-Plan

The plan is the final part of a SOAP Note. It records the actions taken to treat the patient.

This section primarily identifies the need for further testing and consultations with other clinicians in order to treat the patient’s illness.

This section also covers any additional steps that are taken to care for the patient. This section is intended to assist future healthcare professionals in determining what next. Each problem:

  • Lab – Specify the type of testing you want or need. You also state the rationale for choosing each test to resolve the diagnostic uncertainties/dilemma. You should list all tests in order of importance for each diagnosis. If the results of special tests are negative or positive, you should list what to do next.
  • Treatment required (medications ) Here you will indicate the treatments and medications that are needed to meet the patient’s specific needs. You can support your decisions with evidence-based facts from scholarly journals of nursing.
  • Referrals to specialists or consultations If you feel that the patient needs advanced care, you should provide references as to who and when.
  • Counselling and patient education :explain how you will educate patients, including how to adhere to their cultural and linguistic orientations.

NB Bates Guide To Physical Examination has excellent examples of complete H & P note formats.

Jessica Nishikawa has a great video that explains the structure and functions of the SOAP Note for Medical Notes. It can be used to learn more.

Soap Note Templates

Below are some SOAP Note templates that can be used by students in nursing, psychology, and sociology.

Soap Note to Nurses and Medical Students

Date:______________________________________________

Source of information:______________________________________________

Reliability:______________________________________________

  • SUBJECTIVE

Chief Complaint:______________________________________________

HPI: (Use SLIDTA)______________________________________________

Significant PMH/PSH:______________________________________________

Allergies:______________________________________________

Medications:______________________________________________

Social:______________________________________________

Smoking:______________________________________________

ETOH & Illicit drugs: (Ask If there is an area of concern & Utilize CAGE)______________________________________________

Living environment: (Ask If there is an area of concern)______________________________________________

  • OBJECTIVE

Vital signs______________________________________________

Recent Labs: (with a date of draw or EKG/UA/any diagnostics done that pt brings recently done)______________________________________________

General Survey:______________________________________________

Physical Exam:______________________________________________

Lung:______________________________________________

Heart:______________________________________________

(Other tests such as HEENT and abdominal …) may also be indicated.

  • ASSESSMENT

Diagnosis: & ICD 10 code (Your dx is directly related to your CC/subjective/objective) include rationale & references as directed

  1. (Working diagnosis)
  2. Differential diagnoses
  1. ———————————————————————————————————
  2. ———————————————————————————————————
  3. ———————————————————————————————————
  • PLAN

Include references and rationale Medications: (Bullet format)

Labs: That you are ordering Diagnostics: That you are ordering Referral: (To whom are you referring, reason, and how soon should they see this consult)

Patient Education: (Be specific & note if the patient agrees w/ plan or not) Include medication teaching, supportive care, when to return to work…)

Follow Up Return to Office: (Date or time frame)Notify office: (If s/s worsen upon completion of diagnostics)When to seek emergency care/911References

Soap Notes to Coaching

Session Date

Session Time

Type of Session:

Session Location: (Skype/in-person/zoom/email/google meeting)

—————————————————————————————————————————————————————————————————————————————————————-

Subjective: What did the client say?

—————————————————————————————————————————————————————————————————————————————————————-

Objective: What did the customer do? What did the client do?

—————————————————————————————————————————————————————————————————————————————————————-

Assessment: What resources do you need to assess the client?

—————————————————————————————————————————————————————————————————————————————————————-

Plan: What actions did the client suggest?

—————————————————————————————————————————————————————————————————————————————————————-

For coaching sessions, here are some sample SOAP notes

S: It’s getting tiring of being overlooked for promotions. I don’t know how I can make them see my potential.

O – The client placed her head in a chair and began to slump forward.

B – Practice asking for what you want scenarios.
P – Volunteer for positions in the company that are not related to my current job.

Soap notes for counselling

Social workers, psychologists and psychiatrists can use the counseling soap note. Students who wish to create a SOAP note in speech therapy can also use it.

SOAP Sample Notes for Counselling

Example 1 – Speech therapy

S Client Y was alert and walked into the therapy room with no difficulty. He engaged in all the therapeutic activities and was fully involved.

O – Client Y produced the sound /r/ in the first position of single words with 80% accuracy using moderate cues. (Goal met for 2 of 3 consecutive sessions). Client Y also used personal pronouns correctly in 6/10 of the opportunities given. (Progression/Goal not met).

A Client Y continues to make steady progress towards his speech therapy goals.

P – Johnny should continue the current treatment plan for 2 sessions per week, each lasting 30 minutes. This will allow Johnny to maintain his current treatment for an estimated 180 days.

Counselling

S: They don’t appreciate how hard you work.

O The client didn’t sit down when he entered. The client is walking fast and his hands are clenched. The client finally sat down and began fidgeting. The client is ripping through a piece of paper.

A: Looking for ideas to communicate better with their bosses; Looking for ideas for stress management.

P – Practice conflict resolution scenarios; Body scan technique; Take a walk every day during lunch for one week.

Example 3 – Counseling

S – I am tired of not being considered to for promotions despite my hard work, dedication to the growth and many awards.

O – The client is seated in a chair and slumped forward. She is also breathing hard.

A: He needs ideas to ask his boss for promotion; Ideas to ask for consideration in the next promotion window. Needs suggestions for tracking her contributions.

P – Come up with innovative solutions to problems within the company. Volunteer for positions within the company that are not related to your job description. Communicate with bosses frequently and ask for feedback. Advance education through short sources of certification. Practice asking for what you want.

These are some helpful tips for writing a SOAP note

  • Never use layperson references
  • Cite your reasonings in APA and Harvard – The preferred style according to your teacher
  • Publications that are less than five years old should be used
  • Keep your professional voice.
  • Acronyms can be used (check out the list in this guide).
  • Be precise, but not judgmental
  • When writing, don’t confuse pronouns
  • Avoid making subjective statements that are not supported by evidence.
  • Make sure you are clear, precise, and concise
  • Avoid using tentative language like may or seems.
  • Don’t use absolutes like never or always.
  • Use language that is culturally sensitive
  • Refer to evidence-based primary sources (Studies with actual participants).
  • For a scholarly tone, proofread your SOAP note to correct grammar and spelling errors
  • Avoid using textbooks like Goolsby or Bates.
  • Use journals for advanced practice such as Journal for Nurse Practitioners.

Use abbreviations in a SOAP Not

This is a partial list of common abbreviations for medical/nursing terminologies that you can use in writing SOAP notes.

  • : Patient
  • NKDA- No known drug allergies
  • PE – Physical Examination
  • (+) : Present
  • (-) = D$?? = Negative or Absent
  • wnl = Within normal limits
  • d/t- due to
  • CBC = Complete Blood Count
  • Dx- A diagnostic test
  • Ed-education
  • B/C- Because
  • CC- Chief complaint
  • C/o- complained
  • cl-client
  • Monitoring test for Mx
  • Rx-treatments
  • Sx-symptoms
  • W/, w/o, with, without
  • g.- Exempli Gratia, use when giving an Example
  • HPI-history of current illness
  • id est. Use when giving an alternative explanation or writing
  • Min, mod, max- Minimum, Moderate, Maximum
  • PSHx – Past Surgical History
  • PMHx: Past Medical History
  • SHx &FHx – Social & Family History
  • ROS: Review of Systems
  • BMP – Basic Metabolic Panel
  • CMP – Complete Metabolic Panel
  • LFTs: Liver function tests
  • ABG : arterial blood gas
  • UA – Urine analysis
  • HbA1 blood test for diabetes
  • DDx: Differential Diagnosis