Charting a Nursing SOAP Note: Tips and Examples

A nursing SOAP note is a documentation format commonly used by healthcare professionals, including nurses, to record patient information, assessments, and interventions. SOAP stands for Subjective, Objective, Assessment, and Plan, representing the different sections of the note.

Review: Nursing SOAP Notes Examples

• Psychiatric SOAP Note Example
• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Components in a Nursing SOAP Note

Here’s a breakdown of each component:

1. Subjective: In this section, the nurse documents the patient’s subjective information, which includes the patient’s statements, concerns, and observations expressed during the assessment. This may include details about symptoms, pain level, feelings, and the patient’s perspective.
2. Objective: The objective section includes measurable and observable data collected during the assessment. This data can include vital signs, physical examination findings, laboratory results, wound measurements, and any other relevant objective information about the patient’s condition.
3. Assessment: The assessment section involves the nurse’s analysis and interpretation of the subjective and objective data collected. This is where the nurse identifies nursing diagnoses or problems based on the assessment findings. The nursing diagnoses should be supported by evidence and documented using standardized nursing taxonomies such as NANDA-I.
4. Plan: The plan section outlines the nursing interventions and actions that will be implemented to address the identified nursing diagnoses. This includes specific care strategies, treatments, medications, education, and referrals. The plan also includes the expected outcomes or goals for the patient’s care.

Nursing SOAP notes provide a structured framework for documenting patient information in a systematic and organized manner. They promote clear communication and continuity of care among healthcare providers, ensuring that essential information is recorded and shared appropriately.

• It’s important to note that SOAP notes may vary slightly in format and content based on institutional or facility guidelines.
• Additionally, other variations of the SOAP note, such as the SOAPIE (includes intervention and evaluation) or the SOAPIER (includes revision) formats, may also be used in certain healthcare settings.

Format: Charting a Nursing SOAP Note

Here’s a table format for charting a nursing SOAP note:

• In this table format, each section (Subjective, Objective, Assessment, and Plan) has its own column, allowing for clear organization and documentation of the information in a structured manner.
• You can fill in the relevant details and information under each respective section for a comprehensive and concise nursing SOAP note.

Subjective Component of a Nursing SOAP Note

The subjective section of a nursing SOAP note is where the nurse documents the patient’s subjective information, which includes the patient’s statements, concerns, and observations expressed during the assessment. This section provides valuable insights into the patient’s experience and perspective. Here is a detailed breakdown of the components within the subjective section of a nursing SOAP note, including a breakdown of each subcomponent along with examples:

1. Chief Complaint (CC):
   • The main reason for seeking medical attention or the primary concern expressed by the patient.
   • Example: “Patient presents with abdominal pain and nausea.”
2. History of Present Illness (HPI):
   • Detailed account of the current health issue or illness as reported by the patient.
   • Includes information on the onset, duration, location, severity, associated symptoms, and aggravating/alleviating factors.
   • Example: “Patient reports experiencing sharp, intermittent abdominal pain for the past two days. The pain is located in the lower right quadrant and worsens with movement.”
3. Past Medical History (PMH):
   • Relevant information about the patient’s previous medical conditions, surgeries, allergies, and significant past illnesses.
   • Example: “Patient has a history of hypertension and underwent appendectomy three years ago.”
   • In the HPI section, you can apply the OLDCART acronym (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, and Treatment) to gather information about the patient’s current symptoms:
     1. Onset: When did the symptoms start?
     2. Location: Where is the symptom experienced?
     3. Duration: How long does the symptom last?
     4. Character: How would the patient describe the symptom (e.g., sharp, dull, throbbing)?
     5. Aggravating Factors: What worsens or triggers the symptom?
     6. Relieving Factors: What provides relief or alleviates the symptom?
     7. Treatment/Interventions Tried: What measures or interventions has the patient taken to address the symptom?
4. Medications:
   • Documentation of the patient’s current medications, including prescription drugs, over-the-counter medications, and any herbal or alternative remedies.
   • Includes medication name, dose, frequency, and route of administration.
   • Example: “Patient takes lisinopril 10mg orally once daily for hypertension.”
5. Allergies:
   • Documentation of any known allergies the patient has, including medication allergies, food allergies, environmental allergies, or other sensitivities.
   • It is important to note the type of reaction experienced by the patient.
   • Example: “Patient reports an allergic reaction to penicillin resulting in hives and facial swelling.”
6. Social History:
   • Captures information about the patient’s lifestyle, occupation, living situation, support system, and any relevant social factors that may impact their health or care.
   • Example: “Patient is employed as a teacher and lives alone. She has a strong support system consisting of close family and friends.”
7. Psychosocial Assessment:
   • Documentation of the patient’s mental health, emotional well-being, and social functioning.
   • May include information about the patient’s mood, coping mechanisms, stressors, and significant psychosocial factors.
   • Example: “Patient appears anxious and expresses feelings of sadness due to recent loss of a loved one.”
8. Family History:
   • Documentation of relevant medical conditions or diseases that run in the patient’s immediate family.
   • Examples may include cardiovascular diseases, diabetes, cancer, or genetic disorders.
   • Example: “Patient’s mother and sister both have a history of breast cancer.”
9. Review of Systems (ROS):
   • Comprehensive review of various body systems to identify any additional symptoms or concerns the patient may have, even if they are not directly related to the chief complaint.
   • Examples include questions related to respiratory, cardiovascular, gastrointestinal, neurological, musculoskeletal, and genitourinary systems.
   • Example: “Patient denies shortness of breath, chest pain, dizziness, headache, or urinary frequency.”

• By documenting the subjective information under these subheadings, the nurse captures a comprehensive overview of the patient’s health history, current concerns, and relevant contextual factors.
• This helps in formulating a holistic understanding of the patient’s health status and aids in planning appropriate nursing interventions and care.

Objective Component of a SOAP Note

The objective component of a nursing SOAP note focuses on the objective and measurable data obtained during the patient assessment. This section provides information that can be observed, measured, or documented through various assessment techniques. Here are the key components within the objective section along with examples:

1. Vital Signs:
   • Document the patient’s vital signs, including blood pressure, heart rate, respiratory rate, and temperature. These measurements provide essential information about the patient’s physiological status.
   • Example: “BP: 130/80 mmHg, HR: 82 bpm, RR: 18 breaths per minute, Temp: 37.2°C”
2. Physical Examination Findings:
   • Include relevant findings from the physical examination, such as the inspection, palpation, percussion, and auscultation of body systems. This may involve assessing specific body parts, noting abnormalities, and documenting the findings.
   • Example: “Lungs: Bilateral crackles heard on auscultation in the lower lobes. Abdomen: Soft and non-tender upon palpation. Skin: Erythematous rash observed on the left forearm.”
3. Laboratory and Diagnostic Test Results:
   • Record the results of laboratory tests, imaging studies, or other diagnostic procedures that have been performed and are relevant to the patient’s condition.
   • Example: “CBC: Hemoglobin 12 g/dL, WBC 8,000/mm³. Chest X-ray: Consolidation in the right lower lobe consistent with pneumonia.”
4. Objective Observations:
   • Document any objective observations made during the assessment, such as the appearance of the patient, their level of consciousness, mobility, behavior, or specific signs related to the presenting problem.
   • Example: “Patient appears anxious and diaphoretic. Ambulates with steady gait. Shows signs of discomfort when coughing.”
5. Nursing Assessments:
   • Include specific nursing assessments related to the patient’s care, such as wound assessments, neurovascular assessments, pain assessments, or nutritional assessments.
   • Example: “Stage 2 pressure ulcer noted on the sacral area. Pain score reported as 7/10 on the numeric rating scale.”
6. Medication Administration:
   • Document any medications administered to the patient during the encounter, including the name, dosage, route, and time of administration.
   • Example: “Administered 500 mg of acetaminophen orally at 08:00.”

• These components help provide an objective and quantifiable picture of the patient’s condition, allowing for clear and accurate communication among healthcare professionals.
• Remember to document the observations and findings in a concise, factual, and organized manner.

Assessment Component of a SOAP Note

The assessment component of a nursing SOAP note focuses on the nurse’s analysis and interpretation of the subjective and objective data obtained during the patient assessment. It involves identifying patterns, trends, and potential nursing diagnoses or problems. Here are the key components within the assessment section along with examples:

1. Nursing Diagnoses:
   • Identify and document the nursing diagnoses based on the assessment findings. Nursing diagnoses are clinical judgments about actual or potential health problems that nurses can address through nursing interventions.
   • Example: “Impaired Gas Exchange related to ventilation-perfusion imbalance.”
2. Problem Identification:
   • Document any additional health problems or concerns that arise from the assessment data, even if they do not fit into a specific nursing diagnosis category.
   • Example: “Acute pain related to surgical incision.”
3. Risk Factors:
   • Identify and document any risk factors or potential risks to the patient’s health or well-being based on the assessment data. These risk factors may not have manifested as an actual problem yet but have the potential to do so.
   • Example: “Risk for Falls related to impaired mobility and history of previous falls.”
4. Client Strengths and Resources:
   • Assess and document the client’s strengths, abilities, and available resources that can contribute to their care and overall well-being.
   • Example: “Patient has a strong support system consisting of family members who actively participate in the care.”
5. Relevant Findings and Abnormalities:
   • Highlight any relevant findings or abnormalities observed during the assessment that may require further investigation or intervention.
   • Example: “Patient has an elevated body temperature of 38.5°C and reports tenderness in the right lower quadrant.”
6. Psychosocial Assessment:
   • Include an evaluation of the patient’s psychosocial well-being, mental health, coping mechanisms, and any psychosocial factors that may impact their care.
   • Example: “Patient demonstrates signs of depression, including decreased interest in activities and tearfulness.”
7. Client Education Needs:
   • Identify any gaps in the patient’s knowledge or understanding related to their health condition or care, which may require further education and information.
   • Example: “Patient expresses uncertainty about medication administration and side effects.”

• These components help provide a comprehensive assessment of the patient’s health status, including identified nursing diagnoses, problems, risks, and strengths.
• The assessment section is crucial in determining the nursing care needed and guiding the development of the plan of care.
• Remember to document the assessments in a clear, concise, and objective manner, using specific details and supporting evidence from the assessment data.

Plan Component of a SOAP Note

The plan component of a nursing SOAP note outlines the nursing interventions and actions that will be implemented to address the identified nursing diagnoses or problems. It serves as a roadmap for the nursing care provided to the patient. Here are the key components within the plan section along with examples:

1. Nursing Interventions:
   • Document the specific nursing interventions that will be implemented to address the identified nursing diagnoses or problems. These interventions should be evidence-based, individualized to the patient’s needs, and aligned with the established goals and desired outcomes.
   • Example: “1. Administer prescribed bronchodilators and oxygen therapy as ordered. 2. Encourage deep breathing exercises and pursed-lip breathing to improve ventilation. 3. Monitor oxygen saturation and respiratory status regularly.”
2. Collaborative Interventions:
   • Document any collaborative interventions or actions that will be taken in collaboration with other healthcare professionals or disciplines to address the patient’s needs.
   • Example: “Consult with respiratory therapist for assistance with respiratory treatments and therapies.”
3. Patient Education:
   • Include any education or information that will be provided to the patient and their family/caregivers to enhance their understanding, self-care abilities, and adherence to the plan of care. This may involve teaching about medications, self-care techniques, or lifestyle modifications.
   • Example: “Educate the patient on proper inhaler technique and the importance of medication compliance. Provide information on managing shortness of breath and when to seek medical assistance.”
4. Safety Measures:
   • Document any safety measures or precautions that will be implemented to ensure the patient’s safety and prevent potential complications.
   • Example: “Implement fall prevention strategies, including keeping the environment free from clutter and providing non-slip footwear.”
5. Referrals or Consultations:
   • Note any referrals or consultations that need to be made to other healthcare professionals or services to address specific aspects of the patient’s care.
   • Example: “Refer the patient to the physical therapist for gait and balance training.”
6. Evaluation:
   • Include a plan for evaluating the effectiveness of the implemented interventions and documenting the patient’s response or progress toward the desired outcomes. This may involve specific parameters, assessment tools, or timelines for evaluation.
   • Example: “Monitor the patient’s oxygen saturation every 4 hours and assess respiratory status for improvement. Re-evaluate the effectiveness of interventions after 48 hours.”

• These components in the plan section help guide the implementation of nursing care and ensure that the interventions are evidence-based, individualized, and focused on achieving the desired outcomes.
• Remember to document the plan in a clear, concise, and organized manner, providing specific details regarding the interventions, education, safety measures, and evaluations planned for the patient.