Here is a quick overview of the components of a SOAP note. **For a complete breakdown, read this article: How to write a SOAP note: 4 basic components of a chart note.
The acronym SOAP stands for subjective, objective, assessment, and plan.
S- Subjective: Information provided by the patient, family, etc.
- Chief complaint
- History of present illness
- Past medical history
- Allergies
- Medications
- Review of systems
O- Objective: Information that is measured or observed.
- Vital signs
- Physical exam
- Diagnostic data
A- Assessment: Summary of subjective and objective data
- Diagnoses
- Differential diagnoses
- Reasoning for diagnoses/nurse practitioner’s thoughts
P- Plan: Plan of care created by the healthcare provider
- Instructions to the patient
- Medications
- Referrals
- Follow-up appointments
Tips to writing a SOAP note
The SOAP note format creates a systematic, easy to follow chart note. But knowing how to create an easy to read note is harder than it looks! We will go through some tips for creating a SOAP note. Then look at the examples of a SOAP note to see how this format is applied.
Remember the 3 reasons nurse practitioners chart.
Nurse practitioners create chart notes for three reasons. Chart notes are created for continuation of care, billing/coding, and to avoid legal implications. The SOAP notes we create should adhere to all three of these aspects.
Use clear and concise language.
Use simple, concise language that is easy to understand. Avoid medical jargon, acronyms, and abbreviations that may be confusing to patients or other healthcare professionals.
Be informative.
Remember that your SOAP note may be used by other healthcare providers in the future. Be thorough in your documentation, including all relevant information about the patient’s condition, treatment, and progress.
Be objective.
Stick to the facts and avoid making assumptions or judgments about the patient’s behavior or motivations. Avoid any negative or accusing terminology about the patient.
Avoid over charting.
Not only does overcharging consume a lot of the nurse practitioner’s time, it can actually have negative impacts. Remember less is more. For example, if you mention something in the history of present illness, it needs to be addressed through the objective, assessment, and plan. Appropriate evaluation and treatment needs to ensue. Take a look at this article written by The Elite Nurse Practitioner- Charting: Less is More!
Review and revise.
Take the time to review and revise your note before finalizing it. Make sure that all sections are complete, and that your documentation is accurate and clear. Quickly check for spelling or grammar errors. It is important for nurse practitioners to create professional chart notes.
Avoid charting inconsistencies.
Nurse practitioners can prevent a negative outcome in a malpractice cause by avoiding charting inconsistencies. Pay attention to any incorrect information such as erroneous vital signs. A blood pressure of 170/62 is much diffe