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 SOAP nursing note includes your patient’s description of their health history and current symptoms. Subjective data also includes any elements of the patient’s family, social, and medical history. The patient is the best source of information about their health. Therefore, gathering subjective data is essential in making an appropriate diagnosis and developing an effective care plan.
2. Objective Data (O):
Objective data is any information relevant to the patient’s condition that can be measured or observed. Vital signs, diagnostic test results, and the patient’s age are examples of objective data. Objective data is essential in preparing accurate SOAP nursing notes because it reflects things patients may or may not know. For example, the patient may know that his head hurts, which is subjective, but he may not realize that his blood pressure is elevated, which is objective until the nurse measures his blood pressure.
3. Assessment Findings (A):
The assessment part of nursing SOAP notes combines subjective and objective information, which is used to form a diagnosis.
4. Plan of Care (P):
The last step in preparing a SOAP nursing note is to establish and document a treatment plan designed to address the diagnosis formed from the assessment. The part of the note that explains the plan may include orders for further testing, patient education, referrals to specialists, or support services, such as home health or hospice.