How to Write a Perfect Nursing SOAP Note?

GATHERING SUBJECTIVE DATA

STEP #1: Interview the Patient

The first step in writing a SOAP nursing note is to talk with your patient. This is when you gather subjective data. In this step, your goal is to find out what the patient is experiencing from their point of view. Do they feel pain? How bad would they rate their pain? Are they short of breath? Do they have decreased appetite? Anything the patient feels and experiences is subjective and should be recorded.

STEP #2: Use the Mnemonic Device OLDCARTS

When writing a SOAP nursing note, using the acronym OLDCARTS is an excellent way to remember what to ask your patient about symptoms during the interview.
• O- Onset: When did the chief complaint begin?
• L- Location: What part of the body is affected?
• D- Duration: How long have these symptoms been present?
• C- Characterization: Can you describe the pain? (Dull, sharp, aching, throbbing, etc.)
• A- Aggravating or Alleviating Factors: Does anything make the symptoms better or worse?
• R- Radiation? Does the symptom move from one area of the body to another?
• T- Temporal patterns: Does the symptom occur at specific times?
• S- Severity: How would you rate your pain on a scale of 1 to 10?

STEP #3: Collect the Patient’s Personal and Family Medical History

Ask the patient if they have a history of medical problems or surgeries. Gather as much information as possible, including the date of any diagnoses or surgeries, and the doctor(s) who treated them. Ask if there is a family history of health conditions similar to what the patient is experiencing. Keep in mind that you only need family history relevant to your patient’s current issues, not an entire family medical history.

STEP #4: Verify Medications and Allergies, If Applicable

You need to know all medications the patient is taking, including over-the-counter medications and supplements. Record the name, dosage, and frequency of how often the medication has been taken since the onset of symptoms. For example, “APAP 500mg tid X 2days.”

GATHER OBJECTIVE DATA

STEP #5: Measure the Patient’s Vital Signs

After gathering subjective data, you move on to collect objective data, beginning with vital signs. If the patient’s blood pressure, pulse, or respiration are out of normal limits, double-check them to verify accuracy and document they were checked twice. For instance, “Blood pressure 180/96 in right arm. Repeat blood pressure in left arm 182/94.” It is crucial that you verify abnormal findings or inconsistencies because care plans and interventions are based on the findings of your assessment.

STEP #6: Document Objective Findings

In this step of the SOAP nursing note, it is essential to document your findings, not subjective reports. For example, instead of “Patient reports right knee pain,” you would write “Tenderness noted when pressure is applied to the right knee. Redness and bruising also noted on visual inspection.”

STEP #7: Update Test Results

Check for any new laboratory or diagnostic test results and update them in your note. In some cases, if EHRs are used, you may only need to reconcile the electronic document to make sure the results uploaded to the patient’s chart. If you still use paper charts, you should document findings and attach a copy of the test results.

PERFORM AN ASSESSMENT

STEP #8: Observe the Patient for Any Changes Since the Last Assessment

Review the patient’s chart to determine if there is a previous SOAP nursing note. If you are not the first nurse to care for the patient, you want to know what the former nurse observed and documented and observe the patient for any changes since the last assessment. Look for changes in the patient’s level of consciousness, orientation, pain, or response to treatments.

STEP #9: List Patient Complaints Based on Order of Priority

Your SOAP nursing note should focus on the patient’s complaints in the order of priority or severity. If the patient has several complaints and you are unsure which symptom or problem is worse, ask them to rate their symptoms and what they are most concerned about. Look at the subjective and objective data in your note to determine the most probable cause of your patient’s problem, then list the problems according to the order of priority.

STEP #10: Form a Nursing Diagnosis

Forming a nursing diagnosis is one of the essential steps in the nursing process. If there is a clear diagnosis for the patient’s problem, it should be listed immediately after the problem in your note. You can determine a nursing diagnosis based on subjective and objective data. For instance, if your patient has a history of diabetes mellitus and presents with elevated blood glucose, polyuria, polydipsia and reports being “out of sugar medicines,” your diagnosis may be Risk for Unstable Blood Glucose Levels R/T insufficient DM management or medication compliance.

STEP #11: List the Rationale for the Nursing Diagnosis You Choose

After forming a diagnosis, you should cite reasons for choosing that diagnosis based on subjective and objective data.

CREATE A PLAN

STEP #12: List Any Nursing Interventions Which Must Be Implemented

Each diagnosis should be followed by a list of interventions relevant to that specific diagnosis. For example, if your patient has uncontrolled Diabetes, as in the example above, appropriate interventions would include the following:
• Perform FSBS ac and hs
• Educate patient on medication compliance
• Refer to nutritionist for diabetic meal planning

WRITE YOUR NOTE

Step #13: Record Pertinent Patient Information

Your note should begin with the patient’s name, age, sex, and chief complaint. For example, you may write, “54 y/o male presenting to clinic with abdominal pain.”

Step #14: Organize Information in the Note According to the SOAP Format

The way your SOAP nursing note is structured will be determined by your healthcare facility. Some facilities prefer bulleted formats, while others prefer paragraphs under each subheading. Be sure to add all relevant information under the appropriate subheading. On subsequent patient encounters, document any changes from the previous encounter.