A nurse writes SOAP (Subjective, Objective, Assessment, Plan) notes to document a patient's signs and symptoms, to create a nurse diagnosis and to provide a plan of treatment. The SOAP notes are part of a patient's medical and legal record. Nurses record all observations and interventions to provide a picture of the patient's condition, which helps in making a diagnosis. The SOAP notes also provide a record to evaluate treatment success.
Record the subjective information --- the "S" in SOAP --- to document symptoms and complaints as reported by the patient in her own words. Include symptom examples, such as pain, vomiting and diarrhoea. Document the frequency, onset, location and duration of symptoms.
Take measurements and vitals, such as oxygen saturation, blood pressure and pulse to document objective information. This is the "O" in SOAP. Include measurable signs, such as lab test results, vitals, weight and height, in the objective data section.
Perform a head-to-toe clinical exam of the patient's body's systems to rule out various diagnoses. Document exam findings in the "O" section.
Offer a nursing diagnosis in the "A" or assessment section, which includes both subjective and objective information. Confirm and synthesise subjective and objective notes to create assessment data. Record a nursing diagnosis, such as "at risk for a sexually transmitted infection," in this section.
Record, for example, "patient complains of shortness of breath" in the subjective section. Document "patient is wheezing in left and right upper lobes upon auscultation" in the objective section after performing a clinical exam. Record "patient is short of breath" in the assessment section as confirmation of data reported in the subjective and objective sections.
Document the "P," which is the "plan" of treatment, last. Record long and short-term treatment actions, such as "antibiotic therapy," "follow-up X-ray in three weeks," "patient education about Foley catheter insertion" or "physiotherapy consult."
Include relief measures or actions that worsen the patient's symptoms. Provide an evaluation of the success or failure of treatment interventions.
Document SOAP notes on the computer or in pen in the patient's medical record per your institution's documentation protocol. In the event of a lawsuit, SOAP notes can be used in court to provide a record of the health care team's diagnosis and treatment.
If you have questions about how you should document SOAP notes, contact the hospital unit's supervisor or risk management. Purchase additional nurse liability insurance in addition to your employer's insurance plan.
Failure to document properly opens the door to potential lawsuits.