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 nurses and other healthcare providers to create a record of patient progress from the time of admission to discharge. The notes include subjective information gathered from the patient or caregivers, objective data, your assessment/diagnosis, and a plan based on all the data gathered.
Who Developed Nursing SOAP Notes?
Nursing SOAP notes were first introduced in the 1960s by Dr. Lawrence Weed. At that time, there was no standardized process for nursing or medical documentation. Originally, SOAP nursing notes were part of what is known as the Problem-Oriented Medical Record (POMR). Each note identified one problem or diagnosis identified by the primary physician forming only one part of the documentation record. Various disciplines, including nurses, began using the SOAP format to document nursing notes. Today, the POMR and SOAP notes are considered separate types of documentation.
What is the Purpose of Writing a Nursing SOAP Note?
The primary purpose of a nursing SOAP note is to allow clinicians to document patient encounters in a continuous, structured way. These notes help healthcare teams track patient progress by maintaining a record of symptoms, care, and response to treatment. They provide an easy way to track test results, vital signs, patient status changes, and treatment plan updates in one place where all providers have access.