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 a structured format.
Nursing progress notes typically have one field called a “free text” field where you will write narratively about your encounter with the patient. The SOAP note is formatted with individual sections for recording subjective, objective, assessment, and planning data and information.
4 Advantages of Nursing SOAP Notes
There are many types of nursing notes, and each has advantages and disadvantages. The type of note you use is usually determined by the facility where you work. The following are four advantages of using SOAP nursing notes.
ADVANTAGE #1: Nursing SOAP notes facilitate clinical reasoning.
The format used for SOAP notes prompts the nurse to review all evidence, including subjective and objective data and information from the assessment, before reaching a nursing diagnosis. This is essential because if the nurse considers all the subjective and objective data while performing an assessment, they can develop a care plan based on the patient’s individual needs. Individualized care is essential in improving patient outcomes.
ADVANTAGE #2: SOAP Nursing notes promote active listening.
Active listening involves more than hearing with your ears. It also involves hearing what the patient does not say verbally but reveals through nonverbal communication, such as body language and behavior. Because SOAP notes include the element of subjective data, nurses must be intentional about actively listening to patients. Active listening helps foster a more trusting relationship between nurses and patients, which is crucial in providing timely, appropriate care.
ADVANTAGE #3: SOAP nursing notes help create a detailed medical history.
Another benefit of using nursing SOAP notes is that they allow you to create a problem-oriented record that all members of the interdisciplinary team can use. When we write nursing notes focused on the patient’s complaints, we create a timeline of symptoms and a record of the patient’s response to interventions, which is crucial in determining expected outcomes.
ADVANTAGE #4: Nursing SOAP notes help facilitate communication between nurses and doctors.
Although doctors and nurse practitioners make clinical diagnoses, that does not mean that the nurse’s assessment and findings are irrelevant. In fact, the contrary is true, and SOAP nursing notes are one way nurses can communicate their findings to doctors, even if they are not face to face. When used correctly, SOAP notes tell the patient’s story from the onset of symptoms to discharge. Having this type of information at their fingertips makes it easier for doctors to diagnose and treat patients and the interdisciplinary team to communicate effectively.
3 Disadvantages of Nursing SOAP Notes
Although the use of nursing SOAP notes has several advantages, some practitioners feel there are disadvantages to this type of documentation. The following are three of the main disadvantages associated with using SOAP nursing notes.
DISADVANTAGE #1: Many nurses and healthcare providers question the order of the SOAP nursing note format.
Many nurses feel the order of the SOAP format should be changed to APSO. Although the same information is gathered, assessing the patient and creating a plan based on your assessment, then following with subjective and objective data seems to make it easier for nurses and other healthcare providers to navigate the patient’s chart and find pertinent data. The idea behind this thought process is that healthcare workers can acquaint themselves with the client’s present health status and current plan and then determine if changes in the plan are indicated based on subjective and objective findings.
DISADVANTAGE #2: Patients may have several complaints that must be addressed.
Although patients may have several symptoms or complaints, the nursing SOAP note is designed to address one chief complaint. That does not mean other symptoms or concerns are not documented, but they are listed in order of priority, with the plan of care following that list of priorities. As one complaint or issue is improved or resolved, the focus on the SOAP note may change, which can be confusing. This is especially true in hospital settings where nurses work various shifts, and several clinicians may care for a patient during their hospital stay.
DISADVANTAGE #3: Gathering information to determine patient progress can be time-consuming with SOAP nursing notes.
One of the main disadvantages of nursing SOAP notes is that it is challenging to process updates in data over an extended period. Providers must comb through patient charts containing several encounters and SOAP nursing notes before deciphering the effectiveness of treatment and determining whether a new treatment plan is indicated. The time it takes to go through this type of record, many clinicians feel, could be better spent providing direct patient care and assessments.