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Subjective: Ms. H. is a 49 y/o woman here for f/u appt for management of Type 1 DM. Last clinic visit was 6 months ago at which time her A1C was 6.5 Pt. did not reach A1C goal on Metformin. Currently takes Mounjaro 5 mg. once weekly. Pt reports FSBS ranging between 70 and 100…

EXAMPLE #3: Patient with Skin Outbreak Subjective: Patient V.H. is a 60 y/o black male who presented to the urgent care clinic with c/o rash lasting >1 wk. He reports the rash first appeared on his lower back toward the spine but has since spread to the abdomen on his right side. Denies experiencing pain when…

What are the Perfect Examples of Nursing SOAP Notes? (Below are 5 perfect nursing SOAP note examples.) EXAMPLE #1: Patient with Chest Pain and Shortness of Breath Subjective: Mr. Jones is a 71 y/o white male who presented to the ER yesterday at 0800 with intermittent chest pain and S.O.B. Pt. Reports pain has lasted off…

(The following is a step-by-step process to write a perfect nursing SOAP note.) Creating the perfect SOAP nursing note involves four main steps, each of which has small objectives. You must gather subjective data and objective data, perform a nursing assessment, and create a nursing care plan. After the four SOAP steps are complete, you…

Creating thorough nursing SOAP notes requires following the proper format and utilizing pertinent information related to the patient’s condition. One of the things I used to struggle with when preparing SOAP notes was that my love of writing often made my notes look more like long narrative notes instead of formulated SOAP nursing notes. When…

Nursing SOAP notes consist of four elements, subjective data, objective data, your assessment, and the plan of care. Each component of the note should be well-written and address only information relevant to the patient’s immediate concerns or complaints. 1. Subjective Data (S): Subjective data is any information gathered directly from the patient. This element of the…

The terms nursing SOAP note and nursing progress note are often used interchangeably. However, there are some differences. Progress notes are typically used on the initial patient contact, and they include histories, physicals, and SOAP notes. SOAP nursing notes follow the subjective, objective, assessment, and planning format, allowing nurses to document continuing patient encounters using…

  SOAP nursing notes are a type of patient progress note or nurse’s note. It is the documentation used to record information about encounters with patients that follows a specific format. SOAP notes include four elements: Subjective Data, Objective Data, Assessment Data, and a Plan of Care. This type of nurses’ note is used by…

A SOAP note is a written document that a healthcare professional creates to describe a session with a patient/client. The information included is: Subjective, Objective, Assessment, Plan (SOAP). Many fields rely on SOAP notes to transfer information between professionals. The usefulness of SOAP notes is evident based on the following example: A speech-language pathologist (SLP)…

Introduction The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.[1][2][3] This widely adopted structural SOAP note was theorized by Larry Weed almost 50 years ago. It…