Soap Note

Nursing students are required to do SOAP notes for their course work and training in patient assessment and treatment. The writers at Paper Masters help nursing students write SOAP Notes and give an excellent guide as to how to present the information. Get a custom written sample of a SOAP Note to use in your Nursing studies.

S = Subjective data - What is reported by the patient, health care record, or another provider.

O = Objective data - What you personally see and find.

A/P = Assessment/Plan - List problems/diagnoses for the patient, including acute problems, chronic health problems, and preventive care (in that order). Beside each diagnosis, write your plan to address this issue.

At this point in your nursing education, you should use your critical thinking skills to decide what is important to include in an assessment of a patient and what is not. This is the goal of working up a SOAP note. For example, you cannot include everything as you would when doing a complete H&P. If you have additional information you would like to include in your SOAP note (such as a photo of an interesting skin disorder, etc), you may add them at the end.

Example:

The example has been provided as a guide and as an example of what your SOAP note should look like (format). Your SOAP note will need to be completed on a patient that you personally see in practice with a different problem. Make sure that your patient has an actual problem. In other words, no check-ups or well-child visits should be used.

Typical information to base a SOAP note on:

29 year old female presents to your office with c/o dysuria and urgency x 3 days. Describe how results would appear on a U/A and Urine Culture. Described what a NP would see at the visit including the History of Present Illness, family history, social history, physical examination, lab results, plan of care, education, etc. What additional labs would be ordered at this visit? What would you expect to see at goal and why? How would this patient be managed and why? Include patient education in your case. This should be done in SOAP format and include all pertinent lab values.

Things to include for a complete SOAP note:

Subjective - Determine the chief complaint, which is often subjective:
Detail a focused history of present illness:
Onset:

1. When did it start?
2. Did the problem come on suddenly or insidiously?

Location:

Where on/in the body is the problem occurring?

a. What makes it better?

1. Duration:

   a. How long have you been having this problem?

   b. Have you had this problem before?

2. Characteristics:

   a. Description of the problem.

3. Associating Factors:

   a. Does anything accompany the problem?

   b. Is the concern related to some other event?

4. Relieving Factors:
5. Temporal Factors:

   a. Time of day?

   b. Consistent?

   c. When does the problem come and go?

6. Severity:

   a. Has the problem affected you so much that you are no longer able to go to work or school?

   b. Does the problem prevent you from doing any of your regular routine activities?

   c. Detail additional questions that support or rule out possible differential diagnoses by performing a focused review of systems (ROS) of possible associated systems, complaints, or body parts.

7. Allergies.
8. Current medications (prescription, over the counter, home remedies, alternative therapies).
9. Relevant family history.
10. Anything additional important information (e.g., any sick contacts? living/working environment affect on problem?).

Use the Subjective history to guide the focused physical examination. Determine the components of a pertinent physical examination. Construct a physical examination on pertinent systems or body parts. Physical examination should help confirm a differential diagnosis. Any stat labs or tests (e.g., CBC, rapid strep-test, or urine pregnancy test)? Assessment (Diagnosis): Construct a diagnosis(es) based upon your subjective and objective findings. If diagnosis is unknown at this time, the assessment is the chief complaint (e.g., headache, shoulder pain).