How to Write a Nurse's SOAP Note

SOAP notes are a method of charting employed by nurses and other health care professionals. They provide an all-inclusive record of patient interaction, as well as help to standardize charting amongst health care professionals. SOAP notes are also popular because they are easy to review for quality assurance, and they are easy for receptionists, coders and lab technicians to understand, should they need to read or interpret the patient's chart. They paint a complete and accurate picture of the entire visit.

Instructions

1. Write the "S" or subjective section. This includes everything the patient reports. Information in this section usually relates to the patient's complaint in his own words and includes any reported symptoms, their severity and their duration.

2. Write the "O" or objective section. This section details any information you observe while listening to the patient's complaints and performing an examination. If you notice ankle swelling as the patient reports pain, this is the section where you record it.

3. Write the "A" or assessment section. Here, you include your diagnostic nursing assessment, as well as any lab test results you perform. If you are monitoring rather than assessing a patient, you note any changes in the patient's condition here.

4. Write the "P" or plan section. This is the plan for treatment, including what medications or other therapies you will administer or advise. This section should be actionable and thoroughly map out the course of treatment, as well as the intended outcomes and any necessary follow-ups, referrals or additional testing that is needed.

References

• University of Florida Department of Nursing
• Dr. Keenanm MD; Dept of Family Medicine at University of Minesota

Resources

• SOAPNotes discussion at Allnurses.com