Understanding how to write a SOAP note example is essential for nursing students.

SOAP notes serve as a structured method for documenting essential details about a client and the session.    

SOAP notes serve as a highly structured format for documenting a patient’s progress during treatment. As a behavioral health clinician, you’ll find this format particularly useful. Essential components to consider on how to write a SOAP note example.

1. Subjective (S): This section captures relevant client behaviors, feelings, and status. It includes information provided by the client, such as their symptoms, concerns, or emotional state.

Learn how to write a SOAP note example for clinical nursing practice. In this section, you document what the patient shares about their feelings, perceptions, and symptoms related to their diagnosis. For instance, if a client is experiencing depression, you might note that they’ve been crying daily, struggling with sleep, or losing their appetite.

2. Objective (O): In this part, measurable and observable data are recorded. It encompasses vital signs, physical examination findings, test results, and other objective information gathered during the session.

Here, include your observations—measurable, observable data—during the session. Describe what you see: whether the patient is tearful, avoids eye contact, appears disheveled, or hasn’t showered in days.

When documenting, ensure you cover the following points:

Discover the best methods on how to write a SOAP note example efficiently.

SOAP notes play a crucial role in documenting client interactions and ensuring comprehensive care. To create accurate and informative notes, follow these guidelines:

Content to Avoid

• Opinions without Evidence: Avoid making statements without supporting facts. For instance, refrain from saying, “Client was willing to participate,” without providing evidence.
• Assumptive Statements: Base subjective observations on relevant evidence. For example, describe nervousness as evidenced by fidgeting, lack of eye contact, and shortness of breath.
• Negative Connotations: Avoid value-laden language or labels (e.g., “uncooperative,” “obnoxious”).

Objective (O) Section:

• Document factual information about the client, including diagnosis, symptoms, appearance, and mood/affect.
• Observe how the client presents themselves (affect, behavior, eye contact, etc.).
• Include physical, interpersonal, and psychological observations.
• Describe verbal/non-verbal cues and body posture.
• Assess the client’s mental status and ability to participate in the session.
• If applicable, • Reference written materials (reports, tests, medical records).

Master how to write a SOAP note example using these expert tips.       

Examples:

• Positive: “Jon is alert, oriented to time and place, and actively participating during today’s session.”
• Concerning: “Jon displays a mostly flat/blunted affect, and his hygiene is below baseline. He takes several seconds to respond to questions.”
• Chief Complaint and Presenting Problem: Summarize the reason for the client’s visit concisely. For instance, “Jon complains of poor sleep and irritability.”
• Relevant Personal and Medical Issues: Consider any factors that may impact the client’s day-to-day life. These could include personal stressors, medical conditions, or recent life events.
• Client’s Description of Symptoms: Document the client’s account of their symptoms in detail. For Jon, this involves discussing his sleep patterns and exploring potential stress-related causes.
• Progress from Previous Encounters: Reflect on any changes or developments since the last session. In Jon’s case, we may revisit his emotional state and explore triggers like the anniversary of his mother’s death.

3. Assessment (A)

Here, the clinician analyzes the data from the subjective and objective sections. It involves clinical reasoning, differential diagnoses, and identification of patterns or trends.

Tips on how to write a SOAP note example that meets nursing standards. Analyze the information provided by the client. Consider their overall well-being, mental status, and any risk assessments. This section helps you evaluate their progress and make informed decisions.

Avoid common mistakes on how to write a SOAP note example.

Assessment: Integrating Subjective and Objective Information

In the assessment section, we synthesize the subjective (S) and objective (O) data to gain a deeper understanding of the client’s condition. Here are some key points to include:

Professional Interpretation:

• Utilize your clinical knowledge to analyze the information provided by the client during the session.
• Apply relevant models (such as the DSM or therapeutic frameworks) to identify patterns or themes.

DSM Criteria:

• Update the assessment with any observed criteria that align with the client’s symptoms.
• For instance, note if the client exhibits signs of anxiety, depression, or other relevant conditions.

Specific Observations:

• Mention ongoing anxiety experienced by the client.
• Highlight family-related stressors that continue to impact the client.
• Document signs of moderate depression.
• Consider whether the client’s anxiety severity meets the criteria for Generalized Anxiety Disorder (GAD).

Avoid Repetition:

• Refrain from duplicating information already covered in the S and O sections.
• Instead, focus on changes in client progress, regression, or plateau.

4. Plan (P):

The final component outlines the next steps. It includes treatment plans, referrals, follow-up recommendations, and any necessary interventions.

Outline the next steps in treatment. What interventions will you implement? How will you work toward the treatment goals or objectives? Continue reading our step-by-step guide on how to write a SOAP note example.

Treatment Planning in SOAP Notes: A Strategic Approach

In the planning (P) section of your SOAP notes, you’ll outline the next steps based on the information gathered during the session. Here are some key considerations:

1. Focus on Next Steps:
2. Avoid restating the overall treatment plan. Instead, concentrate on specific goals for the upcoming session.
3. Align your planning with the client’s needs and agreed-upon objectives.

• Client-Centric Goals:
• Note nutritional, physical, and medical aspects that contribute to the client’s therapeutic goals.
• Highlight any progression or regression observed during treatment.

• Implementation Details:
• Specify how the client will achieve their goals. For instance:
• “Client will consult with a licensed nutritionist to create a personalized diet and lifestyle plan.”
• “Client plans to start yoga classes at the local gym.”
• “Client commits to attending group therapy sessions for eating disorders.”

• Avoid Language Pitfalls:
• Steer clear of tentative language (e.g., “may” or “seems”) and absolutes (“always,” “never”).
• Write legibly, using culturally sensitive and professional language.
• Proofread your notes for accuracy.

Origins of Nursing SOAP Notes

Dr. Lawrence Weed introduced nursing SOAP notes in the 1960s. At that time, standardized medical documentation processes were lacking.

How to write a SOAP note example for accurate patient documentation.

Originally part of the Problem-Oriented Medical Record (POMR), SOAP notes identified specific problems or diagnoses.

Over time, various disciplines, including nurses, adopted the SOAP format for documenting patient encounters. Today, POMR and SOAP notes are distinct documentation types.

Purpose of Nursing SOAP Notes

Nursing SOAP notes serve to document patient encounters systematically. Clinicians use them to track symptoms, care, and treatment responses. These notes consolidate test results, vital signs, and treatment plan updates in one accessible location for all providers.

Difference Between Nursing SOAP Note and Progress Note

While the terms are often used interchangeably, there are distinctions:

• Progress Notes: Used during initial patient contact, including histories and physicals.
• SOAP Notes: Follow the structured subjective, objective, assessment, and planning format for ongoing patient encounters.

In SOAP notes, each section serves a specific purpose, promoting efficient documentation.

History:

• Dr. Lawrence Weed developed SOAP notes in the 1960s at the University of Vermont as part of the Problem-Oriented Medical Record (POMR).
• Originally associated with specific problems identified by primary physicians, SOAP notes have become widely recognized and used across various healthcare settings.
• While the “POMR” aspect faded, the concise and effective “SOAP” format remains essential for comprehensive patient care documentation.

Advantages and Disadvantages of SOAP Notes

• The SOAP (Subjective, Objective, Assessment, Plan) documentation format offers several benefits and challenges within the healthcare field:

How to write a SOAP note example that improves patient outcomes.

Advantages:

• Standardization: SOAP is a widely adopted protocol, ensuring consistency in documentation across healthcare settings1.
• Clear Organization: It guides practitioners to record relevant information systematically, from patient statements (subjective) to objective observations and treatment interventions.
• Evidence-Based: By emphasizing assessment and planning, SOAP notes promote evidence-based clinical reasoning.

Disadvantages:

• Conciseness Concerns: Some critics argue that SOAP encourages overly concise documentation, potentially omitting crucial details.
• Abbreviations and Acronyms: Overuse of abbreviations can hinder understanding, especially for non-professionals.
• Sequential Approach: SOAP’s structure may prioritize data collection over integrative clinical reasoning2.
• Functional Outcomes Gap: The format lacks specific guidance on addressing functional outcomes or goals.

Writing a SOAP Note: While there’s no strict policy on entry length, ensure your SOAP notes contain essential information. Follow these guidelines from the American Physical Therapy Association:

• Patient self-report
• Specific intervention details
• Equipment used
• Changes in patient status
• Complications or adverse reactions
• Factors influencing the intervention
• Progress toward stated goals
• Communication with other providers and the patient’s family

Key strategies on how to write a SOAP note example effectively.

Components of a SOAP Note

1. Subjective:
2. In this detailed, narrative section, the patient’s self-report is documented. It covers their current condition, symptoms, function, activity level, disability, social history, family history, employment status, and environmental context.
3. Quotations from the patient or caregivers should be enclosed in quotation marks.
4. Include the patient’s goals and their prior response to treatment.
5. Medical information from the patient’s chart can also be included if not directly observed by the therapist.
6. The subjective component captures the patient’s perception of their condition and its impact on rehabilitation and quality of life.
7. Common errors to avoid:
8. Passing judgment on the patient (e.g., “Patient is overreacting again”).
9. Documenting irrelevant information (e.g., patient complaints about a previous therapist).

How to write a SOAP note example for various nursing scenarios.

• Objective:
• This section outlines the therapist’s observations, tests, and measurements.
• Use measurable terms to facilitate reassessment and analyze patient progress.
• Objective results help determine progress toward functional goals and assess treatment effects.
• Indicate changes in the patient’s status and any communication with colleagues, family, or carers.
• Common errors to avoid:
• Providing scant detail.
• Summarizing interventions too broadly (e.g., “ROM exercises given”).
• Assessment:
• The assessment is a critical legal note based on subjective and objective findings.
• Explain the reasoning behind decisions, supporting analytical thinking.
• Generate a prioritized problems list, linking impairments to functional limitations.
• Consider using the International Classification of Functioning, Disability, and Health (ICF) for prioritized problem lists and functional physiotherapy diagnoses.
• Document progress toward stated goals and factors affecting it.
• Include adverse and positive responses observed during reassessment.
• Common errors to avoid:
• Providing vague assessments (e.g., “Patient is improving”).
• Lacking insight.
• Plan:
• The final component outlines anticipated goals, expected outcomes, and planned interventions.
• Specify frequency, intervention details, treatment progression, required equipment, and education strategies.
• Document referrals to other professionals and recommendations for future interventions or follow-up care.
• Describe the patient’s home exercise program (HEP) and steps to achieve functional goals.
• Note any changes to the intervention strategy.
• Common errors to avoid:
• Omitting details about upcoming plans.
• Providing vague plan descriptions (e.g., “Continue treatment”).

A comprehensive tutorial on how to write a SOAP note example: COPD/Pneumonia

Subjective (S):

• The patient reports feeling unwell today, expressing fatigue.
• The patient’s self-perception is essential for understanding their current condition.

Objective (O):

• Auscultation findings reveal scattered rhonchi throughout all lung fields.
• Chest physical therapy (PT) was performed in a seated position (anterior and posterior).
• Techniques included percussion, vibration, and shaking.
• The patient demonstrated a weak combined abdominal and upper costal cough, which was non-bronchospastic, congested, and non-productive.
• The cough/huff was performed with vital capacity (VC).
• Pectoral stretch and thoracic cage mobilizations were performed while seated.
• A towel roll was placed behind the patient’s back to open the anterior chest wall.
• Strengthening exercises were done while standing: hip flexion, extension, and abduction; knee flexion (10 reps x 1 set B).
• The patient follows a home exercise program (HEP) under supervision (evenings with their wife).
• The patient was instructed to hold tissue over the tracheostomy site when speaking to prevent infection and emphasized the importance of staying hydrated.

Assessment (A):

• The patient continues to experience congestion and limitations in coughing productivity.
• Compliance with the evening exercise program has led to increased tolerance and lower extremity (LE) strength.
• Ambulation has not been attempted due to the patient’s reported fatigue.
• The patient should be able to tolerate short-distance ambulation within the next few days.

Plan (P):

• Continue the current exercise plan, including chest PT (CPT).
• Emphasize productive coughing techniques.
• Increase the number of strengthening exercise repetitions to 15.

The ultimate guide on how to write a SOAP note example.

Advantages of Nursing SOAP Notes

1. Facilitates Clinical Reasoning:
2. The SOAP format prompts nurses to review both subjective and objective data before reaching a nursing diagnosis.
3. Individualized care plans can be developed based on a comprehensive assessment, improving patient outcomes.

• Promotes Active Listening:
• SOAP notes include subjective data, encouraging nurses to actively listen to patients.
• Building trust through active listening is crucial for timely and appropriate care.

• Creates a Detailed Medical History:
• Problem-oriented SOAP notes help create a timeline of symptoms and track patient responses to interventions.
• Essential for determining expected outcomes.

• Enhances Communication Between Nurses and Doctors:
• SOAP notes allow nurses to convey findings to doctors, even remotely.
• From symptom onset to discharge, this information aids diagnosis and treatment.

How to write a SOAP note example that stands out in nursing assessments.

3 Disadvantages of Nursing SOAP Notes

1. Order of Format (SOAP vs. APSO):
2. Some nurses and healthcare providers question the order of the SOAP format. They propose using APSO (Assessment, Plan, Subjective, Objective) instead.
3. APSO starts with assessment and plan, making it easier to navigate patient charts and identify relevant data promptly.
4. Addressing Multiple Complaints:
5. SOAP notes focus on one chief complaint, prioritizing it in the documentation.
6. Other symptoms or concerns are documented but listed in order of priority.
7. As issues improve or resolve, the focus may shift, potentially confusing clinicians, especially in hospital settings with rotating shifts.
8. Time-Consuming Data Processing:
9. Gathering information from SOAP notes over an extended period can be time-consuming.
10. Providers must review multiple encounters to assess treatment effectiveness and consider new plans.
11. Some clinicians believe this time could be better spent on direct patient care and assessments.

What Elements Should Be Included in a Nursing SOAP Note?

Subjective Data (S):

• Gather information directly from the patient.
• Include health history, current symptoms, and relevant family, social, and medical details.
• Essential for accurate diagnosis and care planning.

Objective Data (O):

• Measure or observe relevant information about the patient’s condition.
• Includes vital signs, diagnostic results, and age.
• Crucial for accurate documentation.

Assessment Findings (A):

• Combine subjective and objective data to form a diagnosis.
• Summarize the patient’s overall health status.

Plan of Care (P):

• Document a treatment plan based on the assessment.
• Specify further testing, patient education, referrals, or support services.

Creating effective nursing SOAP notes requires adhering to the correct format and focusing on relevant information related to the patient’s condition. Initially, I struggled with writing SOAP notes because my passion for writing often led to overly detailed narrative notes instead of concise, structured SOAP notes.

It’s crucial to keep the content specific and pertinent to the patient’s current complaint or condition. Practical advice on how to write a SOAP note example.

1. Irrelevant Information: The SOAP note should only address the patient’s current issues. Any information that does not relate to the present complaints, symptoms, or treatment plan should be excluded.

• Speculations on Symptoms or Feelings: Your role when writing SOAP notes is to document factual information provided by the patient, caregiver, or objective data. Avoid speculating on what a patient might be thinking or feeling. Instead, focus on documenting observable behaviors and statements from the patient.

• Ambiguous Pronouns: Use clear and specific titles or names instead of vague pronouns. For instance, instead of writing, “She instructed the client to state her name,” it is clearer to write, “The clinician asked the client to state her full name, and the patient was able to do so.”

• Judgmental Language: When documenting information provided by patients or caregivers, remain objective, even if you doubt the accuracy of their statements. For example, if a pediatric patient’s mother claims her child began walking at five months old, rather than writing, “The patient’s mother is obviously mistaken,” you should write, “The patient’s mother reports that the patient took his first steps at approximately five months of age.”

• Slang and Unprofessional Language: SOAP notes should be written in a professional tone, avoiding slang or casual phrases.

For example, instead of writing, “The patient walked in the hallway and had an awesome time,” a more appropriate entry would be, “The patient ambulated in the hallway with minimal assistance, displayed a cheerful affect, and tolerated the activity well.”

How to write a SOAP note example that ensures clear communication.

Writing a flawless nursing SOAP note involves a systematic process broken down into four essential steps: gathering subjective data, collecting objective data, performing a nursing assessment, and developing a nursing care plan. Once these steps are completed, you can compile the information into a comprehensive SOAP note. Below is a detailed guide for each step.

1. Gathering Subjective Data

Step 1: Interview the Patient

Begin by interviewing your patient to collect subjective data. This is the information the patient provides about their symptoms, such as pain levels, shortness of breath, or loss of appetite. Your objective is to document what the patient experiences from their perspective.

Step 2: Use the OLDCARTS Mnemonic

The OLDCARTS acronym is a useful tool for remembering key questions when assessing a patient’s symptoms:

O – Onset: When did the symptoms start?

L – Location: Where is the issue located?

D – Duration: How long have the symptoms been present?

C – Characterization: How does the patient describe the symptoms? (e.g., sharp, dull, throbbing)

A – Aggravating/Alleviating Factors: What worsens or relieves the symptoms?

R – Radiation: Do the symptoms spread to other areas?

T – Temporal Patterns: Are the symptoms associated with a particular time?

S – Severity: How severe are the symptoms on a scale of 1 to 10?

Step 3: Obtain the Patient’s Personal and Family Medical History

Inquire about any previous medical conditions or surgeries. Gather detailed information, including dates and the doctors involved. Also, ask about relevant family medical history related to the patient’s current condition, but avoid unnecessary details.

Step 4: Confirm Medications and Allergies

Document all medications the patient is currently taking, including over-the-counter drugs and supplements. Record the name, dosage, and frequency. For instance, “APAP 500mg tid X 2 days.” Additionally, verify any known allergies.

This approach ensures you have a comprehensive understanding of the patient’s subjective data, which is crucial for writing a thorough and effective nursing SOAP note.

Common errors to avoid on how to write a SOAP note example.

GATHER OBJECTIVE DATA

Step 5: Measure the Patient’s Vital Signs

Once subjective data is collected, the next step is to gather objective data, starting with the patient’s vital signs. If any readings, such as blood pressure, pulse, or respiration, fall outside normal ranges, recheck them to ensure accuracy.

Document both the initial and repeat measurements, e.g., “Blood pressure 180/96 in right arm. Repeat blood pressure in left arm 182/94.” Verifying abnormal findings is crucial, as your care plans and interventions will rely on these accurate assessments.

Step 6: Document Objective Findings

During this step, focus on recording your objective observations rather than subjective reports. For instance, instead of noting, “Patient reports right knee pain,” document your clinical observations: “Tenderness noted upon palpation of the right knee. Redness and bruising observed during visual inspection.”

Step 7: Update Test Results

Review any new laboratory or diagnostic test results and incorporate them into your SOAP note. If you’re using an electronic health record (EHR) system, ensure the results are accurately uploaded and reconciled with the patient’s chart. For paper charts, manually document the findings and attach copies of the test results.

How to write a SOAP note example with accuracy and detail.

PERFORM AN ASSESSMENT

Step 8: Observe the Patient for Any Changes Since the Last Assessment

Begin by reviewing the patient’s chart to check for previous SOAP notes. If other nurses have cared for the patient before you, it’s important to understand their observations and documentation.

Assess the patient for any changes since the last evaluation, focusing on alterations in consciousness, orientation, pain levels, or responses to treatments.

Step 9: Prioritize Patient Complaints

Your SOAP note should prioritize the patient’s complaints based on their severity. If the patient has multiple issues and you’re unsure which is most urgent, ask them to rate their symptoms and express their main concerns.

Use both subjective and objective data to determine the most likely cause of the problem and rank the issues in order of priority.

Step 10: Develop a Nursing Diagnosis

Creating a nursing diagnosis is a critical step in the nursing process. If a clear diagnosis exists for the patient’s problem, include it immediately after listing the problem. The diagnosis should be based on subjective and objective data. Explore how to write a SOAP note example with these guidelines.

For example, if a patient with a history of diabetes mellitus presents with high blood glucose, polyuria, polydipsia, and reports being “out of sugar medicines,” an appropriate diagnosis might be “Risk for Unstable Blood Glucose Levels related to insufficient diabetes management or medication compliance.”

Step 11: Justify the Nursing Diagnosis

After determining a diagnosis, provide a rationale based on subjective and objective data to explain why you chose that diagnosis.

CREATE A PLAN

Step 12: Identify Nursing Interventions

• For each diagnosis, list the necessary nursing interventions. For instance, if your patient has uncontrolled diabetes, as mentioned in the previous example, relevant interventions could include:

• Perform fasting and bedtime blood sugar checks (FSBS ac and hs).
• Educate the patient on the importance of medication compliance.
• Refer the patient to a nutritionist for diabetic meal planning.

How to write a SOAP note example that meets clinical expectations.

Step 13: Document Key Patient Information

• Start your note with basic patient details, such as name, age, sex, and chief complaint. For example: “54-year-old male presenting to the clinic with abdominal pain.”

Step 14: Structure Your Note Using the SOAP Format

• The structure of your SOAP note will depend on your healthcare facility’s preferences. Some facilities may prefer a bulleted format, while others may opt for paragraphs under each section.
• Ensure all relevant information is placed under the correct subheading. For follow-up visits, document any changes compared to the previous encounter.

Detailed instructions on how to write a SOAP note example.

EXAMPLE #1: Patient with Chest Pain and Shortness of Breath

Subjective:

• Mr. Jones, a 71-year-old white male, presented to the ER with intermittent chest pain and shortness of breath (S.O.B.). Pain has persisted for the last six hours.
• Personal history includes hypertension (HTN), high cholesterol, and Type I diabetes. Family history positive for heart attacks, HTN, and diabetes.
• Diagnosed with transient angina after 12-lead EKG, lab draw, and chest CT.
• Currently complaining of S.O.B. with ambulation but denies chest pain. No known allergies.

Objective:

• Alert and oriented x4, pulses + in all extremities.
• Vital signs: BP 146/90, R 24, HR 88, T 98.4, SpO2 92%.
• Lungs clear to auscultation bilaterally. Skin pale, warm, and dry, with slight cyanosis around lips.
• Ambulated with some S.O.B. noted on exertion.

Assessment:

• Activity intolerance evidenced by decreased SpO2, elevated respiratory rate, and cyanosis of lips.

Plan:

• Apply O2 via nasal cannula at 2L continuously.
• Elevate the head of the bed at least 45 degrees.
• Encourage deep breathing exercises.
• Monitor vital signs and patient complaints. Call light accessible for assistance.

How to write a SOAP note example for different patient cases.

EXAMPLE #2: Patient with Productive Cough and Fever

Subjective:

• Patient M.S., experiencing a persistent productive cough for 5 days.
• Symptoms initially “like a cold” but worsened in the last 48 hours.
• Minimal relief from OTC cough suppressant.
• Reports tightness in the chest, difficulty breathing deeply, and a fever of 101.6.
• Denies chills. Thick, white sputum with yellow tinge. Facial tenderness.
• Smoker (1 PPD x 20 years), well-controlled Type 2 Diabetes.

Objective:

• Skin pink, warm, and dry. Mild dyspnea on exertion.
• Vital signs: B/P 120/78, P 84, R 26, T 100.2.
• Lungs clear to auscultation. Normal heart sounds.
• No edema or pulses present in all extremities.
• CXR negative for effusion or pneumonia.

Assessment:

• Recent onset of productive cough, purulent nasal drainage, and low-grade fever.
• CXR negative for pneumonia; no evidence of CHF.

Plan:

• Albuterol inhaler 2 puffs q6hrs.
• Amoxicillin 500 mg bid.
• Educate on inhaler use, smoking risks, and follow-up instructions.

EXAMPLE #3: Patient with Skin Outbreak

Subjective:

• Patient V.H., 60-year-old black male, presents with rash lasting >1 week.
• Rash started on the lower back and spread to the right abdomen.
• Initially painless, now described as a “burning sensation.”
• Increased pain with clothing contact; avoids wearing a shirt.
• Taking APAP 500 mg q4-6 hours with minimal relief (pain rated 6/10).

Objective:

• Skin rash observed on lower back and right abdomen.
• Painful to touch. Skin intact, no signs of infection.

Assessment:

• Painful rash with a burning sensation.

Plan:

• Continue pain management.
• Educate on rash care and follow-up instructions.

How to write a SOAP note example that enhances nursing documentation.

EXAMPLE #4: Clinic Follow-Up – Diabetes Patient

Subjective:

• Ms. H., a 49-year-old woman, presents for a follow-up appointment for Type 1 diabetes management.
• Last A1C was 6.5, not reaching the goal on Metformin.
• Currently takes Mounjaro 5 mg once weekly.
• Reports fasting blood sugar levels between 70 and 100 daily.
• Denies polydipsia, polyphagia, and polyuria.
• Working full-time, trying to make healthier food choices.

Objective:

• Pleasant affect, alert, and oriented x4.
• Vital signs: BP 130/80, P 68, R 18, T 98.1.
• Repeat A1C: 5.4 (lower than previous).
• Labs within normal limits.
• Skin warm, dry, and intact.
• Diabetic foot assessment unremarkable.

Assessment:

• Well-controlled Type 1 diabetes and hyperlipidemia.

Plan:

• Continue current medications and daily blood sugar checks.
• Repeat A1C and lipid panel in 6 months.
• Referral to a nutritionist for dietary guidance.

EXAMPLE #5: Patient with History of Congestive Heart Failure

Subjective:

• Patient G.P., 64-year-old male, presents with S.O.B. at rest and bilateral leg swelling.
• History of CHF, non-compliant with medication.
• Reports productive cough with thick, yellow sputum.
• Denies other symptoms.

Objective:

• Mildly agitated, pale, clammy skin.
• Vital signs: B/P 160/94, P 82, R 24, T 98.3, SpO2 92%.
• Crackles in bilateral lung bases, 3+ pitting edema in lower extremities.
• Atrial fibrillation on EKG, cardiomegaly on CXR.
• CBC and CMP within normal limits.

Assessment: Considering the presence of orthopnea, shortness of breath with minimal exertion, bilateral lower extremity edema, weakness, and fatigue, the patient is likely experiencing an acute exacerbation of congestive heart failure (CHF).

Although shortness of breath and a history of smoking could suggest COPD, the bilateral edema strongly supports a diagnosis of CHF.

Plan: The patient will be admitted to telemetry for oxygen support, assessment for diuresis related to fluid overload, and a comprehensive cardiac evaluation.

An echocardiogram and stress test are scheduled for tomorrow morning.

Continue all home medications except oral Lasix; initiate Lasix 40 mg IV twice daily. Monitor intake and output closely. Expert advice on how to write a SOAP note example.

Educate the patient on the importance of medication adherence and the health risks of smoking on cardiovascular and pulmonary systems.

The patient has agreed to try a nicotine patch to help with smoking cessation.

5 Common Mistakes to Avoid When Writing Nursing SOAP Notes

Writing nursing SOAP notes requires careful adherence to the structured format. However, some common errors are frequently made, which can compromise the clarity and effectiveness of the notes.

Below are five common mistakes nurses make when writing SOAP notes and tips on how to avoid them.

MISTAKE #1: Failing to Identify the Source of Information

• About the Mistake: It’s crucial to specify the source of any information recorded in a SOAP note. Identifying where the information comes from clarifies the patient’s status and highlights who is involved in their care.

• How to Avoid: Always document precisely what was said and who said it. For instance, if a patient reports nausea for two days, write, “Patient reports nausea for two days.”

If the patient’s spouse mentions that the patient seems confused, document, “Patient’s spouse reports that the patient appears confused at times,” and provide examples.

MISTAKE #2: Lacking Supporting Objective Data

• About the Mistake: The objective data section should contain observable and measurable outcomes related to the patient, such as test results or responses to interventions. It’s important that this section is supported by concrete data.

• How to Avoid: Avoid vague statements that lack evidence. Instead of saying, “Patient responds well to verbal cues,” provide specific data, such as, “Patient followed directions to open utensils correctly and answered questions about meal preferences accurately.”

MISTAKE #3: Repeating Subjective and Objective Data in the Assessment Section

• About the Mistake: The assessment section should offer a synthesis of the patient’s progress, lab results, and any changes in symptoms, not a repetition of previous sections.

• How to Avoid: Focus on evaluating the information from the subjective and objective sections and analyze the patient’s progress toward goals or any changes in status.

How to write a SOAP note example using best practices.

MISTAKE #4: Redundant Documentation in the Plan Section

• About the Mistake: The plan section should outline the next steps in patient care, rather than restating the existing treatment plan.

• How to Avoid: Use this section to summarize the next steps based on your latest assessment. For example, if the current treatment is effective, note that the plan should continue. If adjustments are needed, document the new goals.

MISTAKE #5: Assuming the First Symptom Reported is the Chief Complaint

• About the Mistake: The first step in writing a SOAP note is recording subjective data, which sets the stage for the rest of the note. It’s essential to identify the primary issue among multiple symptoms.

• How to Avoid: Carefully evaluate all symptoms reported by the patient and prioritize the chief complaint that most impact their care.

How to Avoid: While patients may present multiple symptoms or complaints, it is the nurse’s responsibility to thoroughly gather information and identify the primary issue. Determining the chief complaint is critical because the rest of the SOAP note is built upon the subjective data collected.

How to write a SOAP note example for nursing students.

Bonus! 5 Expert Tips for Writing Nursing SOAP Notes More Efficiently

Nursing documentation can be time-consuming, but efficiency should not compromise the quality of your work. Here are five expert tips to help you write nursing SOAP notes faster and more effectively.

TIP #1: Choose the Right Time to Write Your Note

To write SOAP notes more efficiently, find a time free from distractions. Avoid writing notes while in the patient’s room. Instead, take notes on paper during your assessment and write the SOAP note immediately after leaving the room. This ensures accuracy and prevents forgetting important details.

TIP #2: Use Clear and Direct Statements

Keep your SOAP notes concise and straightforward. Avoid overly wordy content. For example, instead of writing, “This nurse has carefully considered the patient’s status and concludes he responds well to verbal cues and articulates his feelings appropriately, stating he feels fine,” you could write, “Patient responds well to verbal cues, denies complaints.”

Simple steps on how to write a SOAP note example

TIP #3: Be Specific and Stay on Point

SOAP notes have a straightforward format, allowing you to focus on relevant information. Document only what is pertinent without adding personal opinions or unnecessary details. This helps other healthcare providers quickly understand the patient’s status.

TIP #4: Document Patient Encounters Promptly

Document patient encounters as soon as possible after they occur. Waiting until later increases the risk of forgetting key details, which may require revisiting the patient to gather information, wasting time.

TIP #5: Link Interventions to the Diagnosis

From a nursing management perspective, it’s essential to document patient care with reimbursement in mind. Remember, “If you didn’t document it, it didn’t happen.” Thorough documentation serves as evidence of care provided and justifies reimbursement. By documenting interventions connected to the diagnosis, you ensure clarity and completeness, reducing the need for additional explanations later.

How to write a SOAP note example that is clear and concise

Frequently Asked Questions Answered by Our Expert

1. Who Can Write a Nursing SOAP Note?

Nurses, nursing students, and other healthcare professionals are qualified to write nursing SOAP notes.

• When Should You Write a Nursing SOAP Note?

A nursing SOAP note should be written whenever there is a need to document a patient’s progress. The frequency of notes depends on how often the patient is assessed.

• Do Nurses Write SOAP Notes Every Shift?

In facilities where SOAP notes are utilized, nurses typically write at least one SOAP note per shift.

• How Long Should a Nursing SOAP Note Be?

Most SOAP notes are one to two pages long per patient encounter, each containing one to two paragraphs.

• What’s the Most Important Part of a Nursing SOAP Note?

All parts of a nursing SOAP note are equally important, as they work together to provide a comprehensive assessment using subjective and objective data.

• Can I Use Abbreviations in a Nursing SOAP Note?

Yes, you can use medical abbreviations in a nursing SOAP note. However, it’s best to use the full term to avoid confusion when in doubt.

• What Tense Should Be Used in a Nursing SOAP Note?

Nursing SOAP notes should be written in the present tense, as they document current patient encounters.

• Are Nursing SOAP Notes Handwritten or Printed?

If your facility does not use Electronic Health Records, you may need to handwrite your SOAP notes. Whether handwritten in cursive or print, ensure your note is legible.

1. How Should I Sign Off on a Nursing SOAP Note?

Sign off your nursing SOAP note with your name and credentials.

• What Should I Do If I Forget to Write a SOAP Note on Time?

If you forget to write a SOAP note at the scheduled time, contact your nursing supervisor immediately. Upon returning to work, complete the note with the date of the events, label it as a late entry, and include all relevant information. For example, “8/9/23 (Late entry for care provided on 8/8/23)….” Best practices on how to write a SOAP note example in nursing.

• Can Nursing Students Write a Nursing SOAP Note?

Yes, nursing students can write SOAP notes. Typically, the nursing instructor will review and sign the note after the student.    

Final Thoughts

With so many types of nursing notes, you may wonder, “What exactly is a nursing SOAP note?” This article has explained what a SOAP note is and its components and provided five examples, along with tips on how to write them. Always follow your facility’s documentation protocols, and remember: if you didn’t chart it, it didn’t happen!