{"id":1479,"date":"2013-06-07T09:45:54","date_gmt":"2013-06-07T09:45:54","guid":{"rendered":"http:\/\/www.mometrix.com\/academy\/?page_id=1479"},"modified":"2026-03-28T11:11:49","modified_gmt":"2026-03-28T16:11:49","slug":"soap","status":"publish","type":"page","link":"https:\/\/www.mometrix.com\/academy\/soap\/","title":{"rendered":"SOAP Notes for Medical Workers"},"content":{"rendered":"\n\t\t\t<div id=\"mmDeferVideoEncompass_LNTEJoBhw30\" style=\"position: relative;\">\n\t\t\t<picture>\n\t\t\t\t<source srcset=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.webp\" type=\"image\/webp\">\n\t\t\t\t<source srcset=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.png\" type=\"image\/jpeg\"> \n\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" loading=\"eager\" id=\"videoThumbnailImage_LNTEJoBhw30\" data-source-videoID=\"LNTEJoBhw30\" src=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/circle-play-duotone.png\" alt=\"SOAP Notes for Medical Workers Video\" height=\"464\" width=\"825\" class=\"size-full\" data-matomo-title = \"SOAP Notes for Medical Workers\">\n\t\t\t<\/picture>\n\t\t\t<\/div>\n\t\t\t<style>img#videoThumbnailImage_LNTEJoBhw30:hover {cursor:pointer;} img#videoThumbnailImage_LNTEJoBhw30 {background-size:contain;background-image:url(\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2023\/01\/74-how-to-make-soap-notes-1.webp\");}<\/style>\n\t\t\t<script defer>\n\t\t\t  jQuery(\"img#videoThumbnailImage_LNTEJoBhw30\").click(function() {\n\t\t\t\tlet videoId = jQuery(this).attr(\"data-source-videoID\");\n\t\t\t\tlet helpTag = '<div id=\"mmDeferVideoYTMessage_LNTEJoBhw30\" style=\"display: none;position: absolute;top: -24px;width: 100%;text-align: center;\"><span style=\"font-style: italic;font-size: small;border-top: 1px solid #fc0;\">Having trouble? <a href=\"https:\/\/www.youtube.com\/watch?v='+videoId+'\" target=\"_blank\">Click here to watch on YouTube.<\/a><\/span><\/div>';\n\t\t\t\tlet tag = document.createElement(\"iframe\");\n\t\t\t\ttag.id = \"yt\" + videoId;\n\t\t\t\ttag.src = \"https:\/\/www.youtube-nocookie.com\/embed\/\" + videoId + \"?autoplay=1&controls=1&wmode=opaque&rel=0&egm=0&iv_load_policy=3&hd=0&enablejsapi=1\";\n\t\t\t\ttag.frameborder = 0;\n\t\t\t\ttag.allow = \"autoplay; fullscreen\";\n\t\t\t\ttag.width = this.width;\n\t\t\t\ttag.height = this.height;\n\t\t\t\ttag.setAttribute(\"data-matomo-title\",\"SOAP Notes for Medical Workers\");\n\t\t\t\tjQuery(\"div#mmDeferVideoEncompass_LNTEJoBhw30\").html(tag);\n\t\t\t\tjQuery(\"div#mmDeferVideoEncompass_LNTEJoBhw30\").prepend(helpTag);\n\t\t\t\tsetTimeout(function(){jQuery(\"div#mmDeferVideoYTMessage_LNTEJoBhw30\").css(\"display\", \"block\");}, 2000);\n\t\t\t  });\n\t\t\t  \n\t\t\t<\/script>\n\t\t\n<p><script>\nfunction Rdv_Function() {\n  var x = document.getElementById(\"Rdv\");\n  if (x.style.display === \"none\") {\n    x.style.display = \"block\";\n  } else {\n    x.style.display = \"none\";\n  }\n}\n<\/script><\/p>\n<div class=\"moc-toc hide-on-desktop hide-on-tablet\">\n<div><button onclick=\"Rdv_Function()\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.mometrix.com\/academy\/wp-content\/uploads\/2024\/12\/toc2.svg\" width=\"16\" height=\"16\" alt=\"show or hide table of contents\"><\/button><\/p>\n<p>On this page<\/p>\n<\/div>\n<nav id=\"Rdv\" style=\"display:none;\">\n<ul>\n<li class=\"toc-h2\"><a href=\"#What_are_SOAP_Notes\" class=\"smooth-scroll\">What are SOAP Notes?<\/a><\/li>\n<li class=\"toc-h2\"><a href=\"#SOAP_Note_Example\" class=\"smooth-scroll\">SOAP Note Example<\/a><\/li>\n<li class=\"toc-h2\"><a href=\"#Review\" class=\"smooth-scroll\">Review<\/a><\/li>\n<\/ul>\n<\/nav>\n<\/div>\n<div class=\"accordion\"><input id=\"transcript\" type=\"checkbox\" class=\"spoiler_button\" \/><label for=\"transcript\">Transcript<\/label>\n<div class=\"spoiler\" id=\"transcript-spoiler\">\n<p>Welcome to this video tutorial on SOAP progress notes. <\/p>\n<h2><span id=\"What_are_SOAP_Notes\" class=\"m-toc-anchor\"><\/span>What are SOAP Notes?<\/h2>\n<p>\nNurses and other healthcare providers use the SOAP note as a documentation method to write out notes in the patient\u2019s chart. <strong>SOAP stands for subjective, objective, assessment, and plan.<\/strong> Let\u2019s take a look at each of the four components so you can understand this neat and organized way of note-taking.<\/p>\n<h3>S<\/h3>\n<p>\nS is for &#8220;subjective,&#8221; or what the patient says about what they\u2019re experiencing or feeling. It includes the <strong>patient\u2019s complaints and concerns.<\/strong> In the patient\u2019s own words\u2014why they are here at the clinic or hospital. For example, &#8220;The patient complains of feeling achy all over her body,&#8221; or &#8220;The patient states a sore throat and chills started last night.&#8221; 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\u2019s medical, surgical, family, and social history. Also current medications, allergies, smoking status, drug\/alcohol use, and level of physical activity.<\/p>\n<h3>O<\/h3>\n<p>\nO is for &#8220;objective,&#8221; or what the nurse observes or measures from the patient. This would include <strong>vital signs, test results, facial expressions, and body language.<\/strong> 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, &#8220;The patient\u2019s skin is red and hot to the touch,&#8221; or &#8220;The patient grimaced when he moved his right arm.&#8221; &#8220;The blood pressure reading is low and the heartbeat sounds fast and irregular.&#8221;<\/p>\n<h3>A<\/h3>\n<p>\nA is for &#8220;assessment&#8221; or &#8220;analysis.&#8221; This is the <strong>medical diagnosis or, in our case, the nursing diagnosis<\/strong>, in which the nurse identifies problems or issues that need to be addressed. They would include things such as, &#8220;The patient is at risk for a heart attack as evidenced by chest pain and clammy skin,&#8221; or &#8220;Risk for falls, related to right-sided paralysis.&#8221; The nursing diagnosis analysis step guides us to the next step of planning.<\/p>\n<h3>P<\/h3>\n<p>\nThe P for &#8220;plan&#8221; is where the nurse is noting the chosen interventions that personalize the care of the patient. These interventions are specifically chosen to <strong>move the patient toward the desired outcomes or goals.<\/strong> These interventions need to be based on the patient\u2019s 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.<\/p>\n<h2><span id=\"SOAP_Note_Example\" class=\"m-toc-anchor\"><\/span>SOAP Note Example<\/h2>\n<p>\nLet\u2019s take a look at an example of SOAP note-taking for a patient that recently had surgery.<\/p>\n<h3><span id=\"Subjective_Data\" class=\"m-toc-anchor\"><\/span>Subjective Data<\/h3>\n<div class=\"transcriptcallout\" style=\"text-align: left;\">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.<\/div>\n<p>\n&nbsp;<\/p>\n<h3><span id=\"Objective_Data\" class=\"m-toc-anchor\"><\/span>Objective Data<\/h3>\n<div class=\"transcriptcallout\" style=\"text-align: left;\">\n<ul style=\"margin-left: 20px; margin-bottom: 0px;\">\n<li><strong>Vital signs:<\/strong> Temp max 101.2, BP 124\/79, P 80, R 18<\/li>\n<li><strong>I\/O:<\/strong> Last 24 hrs &#8211; 2,000 mL IV LR, 600 mL out via foley, DTV within 2 hours<\/li>\n<li><strong>Activity:<\/strong> Resting in bed, appears comfortable, not moving much<\/li>\n<li><strong>CV:<\/strong> Heart regular, capillary refill <2 sec, no chest pain<\/li>\n<li><strong>Resp:<\/strong> Lungs clear bilaterally<\/li>\n<li><strong>Abdomen:<\/strong> Bowel sounds hypoactive, mild distension<\/li>\n<li><strong>Skin:<\/strong> Incision to lower abdomen intact with dermabond, no redness or drainage<\/li>\n<li><strong>AM Labs:<\/strong> CBC, H\/H 9.8\/30.2, WBC 20,000<\/li>\n<\/ul>\n<\/div>\n<p>\n&nbsp;<\/p>\n<h3><span id=\"Assessment\/Analysis\" class=\"m-toc-anchor\"><\/span>Assessment\/Analysis<\/h3>\n<div class=\"transcriptcallout\">Risk for infection as evidenced by elevated temp and WBC.<\/div>\n<p>\n&nbsp;<\/p>\n<h3><span id=\"Plan\" class=\"m-toc-anchor\"><\/span>Plan<\/h3>\n<div class=\"transcriptcallout\" style=\"text-align: left;\">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.<\/div>\n<hr>\n<h2><span id=\"Review\" class=\"m-toc-anchor\"><\/span>Review<\/h2>\n<p>\nHere\u2019s a question to get you thinking:<\/p>\n<p>The A in &#8220;SOAP&#8221; progress notes includes which of the following:<\/p>\n<ol>\n<li>Interventions<\/li>\n<li>Measurable data<\/li>\n<li>Nursing diagnosis<\/li>\n<li>Patient complaints\/concerns<\/li>\n<\/ol>\n<p>If you chose 3, nursing diagnosis, you\u2019re 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.<\/p>\n<p>Thank you for watching this video tutorial on SOAP progress notes for nurses!<\/p>\n<\/div>\n<\/div>\n\n<div class=\"home-buttons\">\n<p><a href=\"https:\/\/www.mometrix.com\/academy\/patient-care\/\">Return to Patient Care Videos<\/a><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Return to Patient Care Videos<\/p>\n","protected":false},"author":1,"featured_media":91039,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":{"0":"post-1479","1":"page","2":"type-page","3":"status-publish","4":"has-post-thumbnail","6":"page_category-general-patient-care-videos","7":"page_category-patient-care-videos","8":"page_category-safe-and-effective-care-environment","9":"page_category-video-pages-for-study-course-sidebar-ad","10":"page_type-video","11":"subject_matter-nursing"},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/1479","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/comments?post=1479"}],"version-history":[{"count":5,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/1479\/revisions"}],"predecessor-version":[{"id":280847,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/pages\/1479\/revisions\/280847"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/media\/91039"}],"wp:attachment":[{"href":"https:\/\/www.mometrix.com\/academy\/wp-json\/wp\/v2\/media?parent=1479"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}