SOAP -- Subjective, Objective, Assessment and Plan -- notes may be used by any medical professional, but each discipline uses terminology and other details relevant to the specialty. Nursing SOAP notes, for example, may use nursing diagnoses, while physicians' SOAP notes include medical diagnoses. A good SOAP note should clearly describe what the patient said; what the writer saw, heard or smelled; results of monitoring or diagnostic tests; the writer’s assessment of the patient’s situation, problems or condition; and the plan of care.
SOAP Notes Basics
The purpose of a SOAP note is to organize information about the patient in a concise, clear manner. SOAP notes are meant to communicate findings about the patient to other nurses and health care professionals. The nurse should use only standardized abbreviations, and if writing in longhand, should ensure her writing is clear and legible.
Nurses who use electronic documentation should follow the template or other organizational structure in the software. Some electronic medical records systems provide a checklist of findings to use in constructing the SOAP note. A SOAP note should be detailed enough to provide an accurate picture, but otherwise should be as brief as possible. Some organizations may have specific guidelines about SOAP notes and where they are used in the medical record.
Before the nurse can write a SOAP note, she must conduct a physical exam of the patient and ask questions intended to elicit the patient’s emotional state, knowledge of his condition and other information. In some instances -- such as home care -- the examination includes the patient's environment. Vital signs, such as the blood pressure, temperature, pulse and respiration, are important to the SOAP note. Other data may also be included; if a patient is on cardiac monitoring, for example, the nurse may include the heart rhythm. During the examination, the nurse prompts the patient to, for example, describe his pain and rate its intensity.
Structuring the SOAP Note
Many patients have multiple problems the nurse must address. This task is easier if the nurse uses the problems to structure the SOAP note. For example, a patient may have heart disease, diabetes, severe anxiety and a surgical wound. The nurse would divide each section of the SOAP note according to these major issues, and address each in a paragraph. For example, under "heart disease," she would include information about the patient’s pulse, blood pressure and heart rhythm, and whether the patient reports chest pain. She would also note laboratory tests relevant to heart disease. If she identified a need for patient education or information that should be reported to the physician, those items would be included in her assessment and plan as well.
Assessment and Planning
The assessment section of a SOAP note is just what it sounds like: the nurse documents her assessment of the patient’s physical and emotional status. For example, her SOAP note might state, “Wound edges slightly reddened -- patient at risk for infection. Pt. very tearful when talking about the possibility of not being able to go home -- fear of dependency.” The second section in each sentence is a nursing diagnosis.
In the plan section of a SOAP note, the nurse documents the actions she has taken or will take. For example: “Continue to monitor surgical wound. Provided emotional support and encouraged patient to talk about fears. Social services referral to discuss rehab or other options for discharge.” Note that SOAP notes must always be signed by the writer.