Frequently Asked Questions Answered by Our Expert
1. Who Can Write A Nursing SOAP Note?
Nurses, nursing students, and other healthcare providers can write nursing SOAP notes.
2. When To Write A Nursing SOAP Note?
You should write a nursing SOAP note anytime there is a need to document your patient’s progress. The frequency of notes will depend upon how often the patient is seen/assessed.
3. Do Nurses Write SOAP Notes Every Shift?
In facilities where SOAP nursing notes are used, nurses typically write a SOAP note at least once each shift.
4. Ideally, How Long Should Nursing SOAP Notes Be?
Most SOAP nursing notes are one to two pages long for each patient encounter. Each section may have one to two paragraphs.
5. What’s The Most Important Part Of A Nursing SOAP Note?
It takes a combination of subjective and objective data for the nurse to apply critical thinking and a systems-approach to assessing a patient and implementing care. Therefore, all parts of a nursing SOAP note are equally important.
6. Can I Use Abbreviations In A Nursing SOAP Note?
Yes, you may use abbreviations in a nursing SOAP note for medical terms. However, it is best to use complete words when possible. If you are unsure of how to correctly use an abbreviation, it is always best to err on the side of caution and spell out the words.
7. What Tense Do I Write A Nursing SOAP Note?
Because nursing SOAP notes are written with each patient encounter, they should be written in present tense.
8. Are Nursing SOAP Notes Handwritten Or Printed?
If you work in a facility that does not use Electronic Health Records, you may need to manually write your notes. Nursing SOAP notes may be handwritten in cursive or print. The most important thing is to ensure your note is legible.
9. How To Sign Off A Nursing SOAP Note?
You should sign off on a nursing SOAP note with your name and credentials.
10. What Happens If I Forget To Write A SOAP Note On The Time It Should Have Been Written?
Failure to write a SOAP nursing note at the time it should have been written can have negative consequences for nurses, healthcare teams, and their patients. If you forget to write a note and have already left work, call your nursing supervisor immediately and report the oversite and any important patient information. Upon returning to work, you should complete your note by recording the date of the events and any information necessary, and document that the entry is a late entry.
For example, you may write “8/9/23 (Late entry for care provided on 8/8/23)….”
11. Can A Nursing Student Write A Nursing SOAP Note?
Yes, nursing students can write a nursing SOAP note. It is customary for the nursing instructor to sign behind the student at the end of the note.