When writing nursing SOAP notes, it is essential to follow the format carefully. Some of the most common mistakes nurses make when writing these notes are easily avoidable. The following are five of the most common mistakes made when writing SOAP nursing notes and how to avoid them.
MISTAKE #1: Not Naming the Source of Information
About the Mistake:
When writing a SOAP nursing note, it is essential to state the source of any information you record in the note. Referencing the source of any data you gather will help paint a more clear picture of the patient’s status and shed light on who is available and involved in their care.
How to Avoid:
The best way to avoid this mistake is to document exactly what you are told and by whom. For example, if the patient reports feeling nauseated for the last two days, you will write, “Pt. reports nausea X2 days.” If your patient’s spouse tells you she seems confused lately, document by saying, “Pt.’s spouse is present and reports pt. seems confused at times,” and give examples.
MISTAKE #2: Not Providing Supporting Objective Data
About the Mistake:
The objective data section of the SOAP nursing note is where you document your observation of the patient. This section should include interventions and patient responses to them. It should also include measurable outcomes related to your patient such as test results, the percentage of completed goals, and all other quantitative data.
How to Avoid:
You can avoid this mistake by avoiding general statements that lack supporting data. For instance, if you asked the patient to perform a task, instead of saying, “Pt. Responds well to verbal cues,” you could say, “Pt. responds to verbal cues by following directions for opening utensils and using appropriate utensils. Pt. also responded appropriately to questions about his preferred meal stating he would rather ham instead of turkey.”
MISTAKE #3: Repeating Subjective and Objective Data in the Assessment Section
About the Mistake:
The nursing SOAP note is designed to follow a set format, and when followed correctly, information does not become repetitive. The assessment section should be used to describe your analysis of the patient’s progress, laboratory and diagnostic test results, and any new or worsening symptoms.
How to Avoid:
Instead of rewriting what is in the subjective and objective section, take a few moments to review the information and review your patient’s progress toward goals or regression in status. Assess factors that contribute to these changes and document them.
MISTAKE #4: Rewriting the Whole Treatment Plan
About the Mistake:
As nurses, we know the importance of thorough documentation. There is a difference in being thorough and being repetitive, however. When writing a nursing SOAP note, the plan section of the note should not repeat information that has already been recorded.
How to Avoid:
Instead of rewriting the treatment plan, use this section of the note to create an outline of the next steps in patient care. Your next steps should be based upon the findings of your most recent assessment. For example, if your patient is responding well to treatment and reaching goals, you may document and say, “Pt. response to current treatment plan effective; continue current plan and reevaluate progress.” On the other hand, if your patient is not responding well to the current treatment plan, this is the place at which you will create new goals and objectives.
MISTAKE #5: Assuming the First Complaint is the “Chief” Complaint
About the Mistake:
When writing a SOAP nursing note, the first step is to record subjective data. The information in this section lays the foundation and sets the context for later sections. When patients report several symptoms, there is typically one major or chief complaint.
How to Avoid:
Although patients may report several symptoms or complaints, it is the nurse’s responsibility to gather as much information as possible and try to determine the primary cause of the patient’s complaints. Finding the primary complaint is the most critical step in completing a SOAP nursing note because all other sections of the note should build upon the subjective data you collect.