If you need to write a SOAP note and you do not know how to go about it, do not panic. Writing a SOAP note can be a challenging experience for a first-timer. Nevertheless, anyone can write an excellent SOAP note with the right information.
This guide presents all the necessary information to write a professional SOAP note. The guide has been prepared by our top nursing writers and it is structured in an easy-to-understand format. It has all the key facts you need to know about SOAP notes. It also has the exact steps you need to follow to write the perfect SOAP note.
Remember, if you are overwhelmed when writing a SOAP note or any other type of nursing file or assignment, you can simply order it from us. We have some of the best nursing writers and editors in the industry.
Let’s begin.
SOAP is an acronym. The letters S.O.A.P stand for Subjective, Objective, Assessment, and Plan, respectively. A SOAP note is a special way of recording patient information for assessment, diagnosis, and treatment. It involves capturing and organizing patient information following a specific structure.
SOAP notes help clinicians to collect both subjective and objective information correctly. This improves the assessment, diagnosis, and treatment of patients. These notes also help healthcare workers to communicate better because they are familiar to most healthcare professionals.
SOAP notes are often considered a crucial part of a patient’s medical records. Because of this, they must be written in a manner that is clear and that follows the standard structure.
As a nurse, you should always take patient information or details using the SOAP note format or structure. This is because the SOAP note format is a standardized way of taking patient information that other nurses and healthcare workers can quickly read and understand. Therefore, to ensure efficient communication, you should always use the standard SOAP note format to record patient information.
Another reason you should always take patient information using the SOAP note format is that the format ensures easy monitoring of patient status. The way the standard SOAP note is organized makes it easy for healthcare practitioners to know what they need to know quickly. This makes patient monitoring easier and faster.
Now that you know the meaning of SOAP notes and their importance, it is time to get to the important stuff. Let’s first look at the structure or anatomy of a standard SOAP note.
As mentioned a few moments ago, SOAP is an acronym. The letters S.O.A.P stand for Subjective, Objective, Assessment, and Plan, respectively.
Under the S (Subjective assessment) section of your SOAP note, you should collect subjective information. Subjective information is the information given by patients. This information is usually helpful in identifying the problem. However, it is referred to as subjective assessment because it is from personal views, feelings, experiences, and so on.
There are three pieces of subjective information you should collect in this section of your SOAP note. The Chief Complaint (CC), the History of Present Illness (HPI), and the general patient history.
The CC is the main problem the patient is complaining about. It could be a symptom, a previous diagnosis, or a condition. Examples of chief complaints include shortness of breath, reduced appetite, constant headaches, fever, and chest pain. When recording CC, it is important to be brief.
HPI is collected in an elaborate manner. The information is collected by asking the patient to expand on their CC. The information collected under HPI includes an opening line stating the age, the sex, and the CC of the patient. It also includes the onset, the location, the duration, the characterization, the radiation, and the severity of the CC. When collecting HPI information, it is important to focus on quality rather than quantity.
General patient history is the last piece of information collected under the subjective assessment section of the SOAP note. The general patient history that needs to be collected in a typical SOAP note includes medical history (present or current conditions), surgical history, family history, and social history. The personal history collected needs to include current medication.
Under the O (Objective assessment) section of your SOAP note, you need to collect objective data. The objective data you need to collect includes General Survey, Vital Signs, Range of Motions, and Laboratory Results.
A standard SOAP note objective assessment section will have spaces for entering all types of objective data including HEENT, special tests, imaging results, laboratory data, physical exam findings, abdominal, lymph, and circulation data.
This section will also have a subsection for the Review of Systems (ROS). This is often a list of questions designed to help clinicians to uncover symptoms perhaps not mentioned by a patient. The questions usually review the general body system, the musculoskeletal system, and the gastrointestinal system. Questions under the general body system sub subsection can help to uncover symptoms such as reduced appetite, weight loss and so on.
Questions under the musculoskeletal system sub subsection can help to uncover symptoms such as reduced range of motion and toe pain. Lastly, questions under the gastrointestinal system sub subsection can help to reveal symptoms such as stomach cramps and abdominal pain.
When writing the objective assessment section of your SOAP note, try to be as objective as possible. You should also try to be as clear as possible. Of course, you should also try to capture as many details as possible but you should not be verbose.
Under the A (Assessment) section of your SOAP note, you need to detail the working diagnosis based on the information you have captured in the S (Subjective) and O (Objective) sections of your SOAP note. In other words, in this section of your SOAP note, you need to synthesize the data you have gathered so far to complete your work.
The best way to approach this section of the SOAP note is to assess the status of the patient by analyzing the problem, analyzing the objective data, and diagnosing the problem.
In case of a repeat visit, it is in this section that a clinician is supposed to capture the changes to the objective and subjective information in the patient.
This section typically includes two key subsections — working diagnosis and differential diagnosis. The working diagnosis subsection is where you should list the problems beginning with the most important one. In this case, the problem is the diagnosis. In other words, it is what is affecting the patient based on the information you have collected. The most important diagnosis is the primary diagnosis. It should be stated in words alongside its ICD-10 code.
The second subsection is the differential diagnosis section. It is in this section that you should list other possible diagnoses. You should list them from the most likely one to the one that is least likely. You should also detail your thought process. It is in this subsection that you should fully explain your decision-making process.
And the best way to do this is to state a differential diagnosis and then to detail the rationale behind including the diagnosis. Do this for all your differential diagnoses. When providing the rationale behind a diagnosis, you should do it using evidence from credible nursing or medical literature sources.
And don’t forget to mention the signs or symptoms in the subjective or objective assessment sections that led to each diagnosis.
This is the last section of a SOAP note. It is perhaps the most important part of a SOAP note. It is in this part of your SOAP note that you should document the interventions you have identified for the treatment of the diagnosed problem.
This section has space for additional consultation and testing. However, its main purpose is to document the interventions or steps to be taken to assist the patient. When writing this section of the paper, you will typically include four subsections: lab, therapy needed, consults, and patient education.
Under the lab subsection, you should note any tests you want to be carried out at the laboratory. You should state the reason or rationale for each test. The best way to write the tests you want is by starting from the most important one to the least important one. The tests should be listed next to the related diagnosis. What should follow in case of a negative or positive test should also be written next to each test.
Under the therapy needed subsection, you should indicate the interventions and medications needed to address the diagnosis or diagnoses. The interventions and medications should be supported by evidence from credible nursing literature.
Under the consult subsection, you should indicate if the patient needs more advanced care. The information should include a reference to be contacted and how soon.
The patient education subsection is the last subsection of a typical SOAP note. You should include information on how you will conduct patient education. The patient education information should consider the customer's cultural and linguistic orientation.
As you can see from the information above, the structure of a standard SOAP note is pretty complicated as you can see. It has several sections and subsections that are very important and that need to be written accurately and concisely.
Soap Note Template for Nurses
SUBJECTIVE ASSESSMENT
OBJECTIVE
ASSESSMENT
PLAN
References
We have covered some tips below to help you polish your SOAP notes and get the best grades.
Trying to capture details directly in the SOAP note when you are with a client is wrong. You should simply use a SOAP note template as a guide to help you ask the right questions. You should note the answers down somewhere else. And then, you should transfer the answers to a SOAP not as soon as you can after the patient has left. Doing this will help you avoid making many errors in the SOAP note, as many clinicians do when they rush to fill in SOAP notes when in session with clients.
It is very important to use formal language throughout your SOAP note. Doing this and avoiding informal language throughout your SOAP note will help to make your SOAP note very professional. It will reduce confusion, especially when writing one for work. And when you are writing a SOAP note for class, using formal language throughout will ensure you get a good score for language.
A SOAP note is not an article or an essay; it is a short piece of writing supposed to capture patient assessment, working diagnosis, and treatment as briefly as possible. It should never be wordy. When you have written something in your SOAP note that is too wordy, you should simplify it. Delete all the extra words you do not need. Of course, this is only possible when typing a SOAP note on a computer. When you are writing one physically, it becomes difficult to edit. You may have to start over on a new SOAP note.
Overly negative or positive phrasing in your SOAP note will make it look clumsy and judgmental. You should avoid using unnecessary words to avoid appearing overly negative or positive in your writing. You should also try as much as you can to avoid exaggerations.
When other healthcare practitioners read a SOAP note, they expect to understand everything easily and quickly. So, to make your SOAP note easy to understand, ensure everything you write is clear and concise. After writing your SOAP note, re-read and remove all unclear sentences or notes from it if writing it on a computer.
When providing rationales for diagnoses and medications, reading and citing credible nursing or medical literature is imperative. This will help to complete your SOAP note when writing it for class work. And when you do this in a professional setting, you enable anyone else who wants more information to find and read it quickly.
When writing a SOAP note, try as much as you can to avoid including unsourced statements or opinions. This will help a great deal in making your work look professional.
Avoid writing anything in your SOAP note in a language that can be considered disrespectful by a section of society. Never write anything considered disrespectful, abusive, or discriminatory because it is never right, and you never know who will read it.
You must cite the ideas and facts you use in your SOAP note. And when you do, you should ensure the literature is recent and not old.
Here is a list of abbreviations used in professional SOAP notes. You can use them when writing a SOAP note as a nursing student, but it is not a must.
Writing a SOAP note without knowing the right structure and template is a pain in the ass. It is a laborious process that will leave you second-guessing yourself every step of the way. However, the fact that you have read this entire post means you now have everything you need to write a professional SOAP note. We can help you with your online nursing class.
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