How to Make SOAP Notes for Medical Workers
S is for “subjective,” or what the patient says about what they’re experiencing or feeling. It includes the patient’s complaints and concerns. In the patient’s own words—why they are here at the clinic or hospital. For example, “The patient complains of feeling achy all over her body,” or “The patient states a sore throat and chills started last night.” In this section, you want to describe the onset, location, frequency, intensity, duration, and what makes it better or worse. If this is the first time the patient is being seen, you also need to include the patient’s medical, surgical, family, and social history. Also current medications, allergies, smoking status, drug/alcohol use, and level of physical activity.
O is for “objective,” or what the nurse observes or measures from the patient. This would include vital signs, test results, facial expressions, and body language. For example, BP, pulse, temperature, weight, findings from a physical exam, and results from lab or diagnostic tests. Some examples from a physical exam include things such as, “The patient’s skin is red and hot to the touch,” or “The patient grimaced when he moved his right arm.” “The blood pressure reading is low and the heartbeat sounds fast and irregular.”
A is for “assessment” or “analysis.” This is the medical diagnosis or, in our case, the nursing diagnosis, in which the nurse identifies problems or issues that need to be addressed. They would include things such as, “The patient is at risk for a heart attack as evidenced by chest pain and clammy skin,” or “Risk for falls, related to right-sided paralysis.” The nursing diagnosis analysis step guides us to the next step of planning.
The P for “plan” is where the nurse is noting the chosen interventions that personalize the care of the patient. These interventions are specifically chosen to move the patient toward the desired outcomes or goals. These interventions need to be based on the patient’s specific needs and abilities. In order to be effective, they need to be realistic and measurable, so they can be evaluated. This may include medications, treatments, therapy, education, or referrals.
Let’s take a look at an example of SOAP note-taking for a patient that recently had surgery.
Post-op day 1. Patient reports some discomfort with movement, but no pain when lying in bed. Foley catheter has been removed, but patient has not yet been out of bed and is due to void. No flatulence since surgery, patient remains on clear liquid diet.
- Vital signs: Temp max 101.2, BP 124/79, P 80, R 18
- I/O: Last 24 hrs – 2,000 mL IV LR, 600 mL out via foley, DTV within 2 hours
- Activity: Resting in bed, appears comfortable, not moving much
- CV: Heart regular, capillary refill <2 sec, no chest pain
- Resp: Lungs clear bilaterally
- Abdomen: Bowel sounds hypoactive, mild distension
- Skin: Incision to lower abdomen intact with dermabond, no redness or drainage
- AM Labs: CBC, H/H 9.8/30.2, WBC 20,000
Risk for infection as evidenced by elevated temp and WBC.
Encourage the patient to cough/deep breathe, and use an incentive spirometer. Assist the patient to ambulate to the bathroom and in hallways. Administer pain medication as needed for pain when moving/walking. Continue to monitor vital signs and lab results.
S for subjective
O for objective
A for analysis/assessment
P for plan
Here’s a question to get you thinking:
The A in “SOAP” progress notes includes which of the following:
2. Measurable data
3. Nursing diagnosis
4. Patient complaints/concerns
If you chose 3, nursing diagnosis, you’re right! The A is for assessment/analysis, in which the nurse identifies problems or issues that need to be addressed and writes a nursing diagnosis.
Thank you for watching this video tutorial on SOAP progress notes for nurses!