When it comes to nursing documentation, we all want to save time. However, it is crucial that saving time does not come at the cost of poor performance on our part. There are a few things you can do to help write nursing SOAP notes faster and more efficiently. The following are a few expert tips I suggest to help you.
TIP #1: Write your note at an appropriate time.
The first step in writing nursing SOAP notes in less time is to find the right time, free of distractions, to write your note. Avoid writing the note while you are in the room with the patient. Instead, take a pen and paper with you to jot down important information while interviewing and assessing your patient. Then, write the note when your assessment is complete, and you have left the patient’s room. Keep in mind that your note should be written as soon as possible after your patient session has ended so you do not forget important information.
TIP #2: Use direct statements, avoiding overly wordy content.
Your nursing SOAP note should be clear and concise, providing direct insight into what the patient is experiencing without embellishments.
For example, avoid writing a statement like this: “This nurse has made careful consideration of the patient’s status and concludes he responds well to verbal cues and articulates his feelings appropriately, stating he feels fine.”
Instead, you may write, “Pt. responds well to verbal cues, voices no complaints upon assessment.”
TIP #3: Be specific and to the point.
The format for SOAP nursing notes is simple, which makes it easier to get to the point. Document only pertinent information and do so without personal opinions or embellishments. Keeping your note specific and to the point will help other practitioners follow the patient’s progress without having to weed through unnecessary information.
TIP #4: Document each patient encounter as soon as possible.
If you document patient encounters when they occur instead of waiting until the end of your shift, you can save time. Conversely, waiting until a later time to document in your SOAP nursing note increases the chance of forgetting important information, which could make you have to return to the patient’s room to gather data.
TIP #5: Connect interventions with your diagnosis.
From a nursing management perspective, it is crucial for nurses to document about patient care with reimbursement for services in mind. One thing I have always told nursing students is, “If you did not document it, you did not do it.” That may seem harsh or a little over the top, but in the eyes of the law, documentation is the only proof you have that you provided care. In the eyes of insurance companies and other pay sources, documentation is your proof that services were provided, and payment is due. If you write your nursing SOAP note with reimbursement in mind, you do not have to go back later and try to connect the dots to make sure the patient can be billed.
My Final Thoughts
With so many types of nursing notes available, it is normal to wonder, “What is a nursing SOAP note?” In this article, I shared information about what a SOAP nursing note is, the elements included in the notes and 5 perfect nursing SOAP note examples + how to write them. As a nurse, I encourage you to follow your facility’s protocol for nursing documentation carefully and to remember, if you did not chart it, you did not do it!