How to Make SOAP Notes for Medical Workers

Welcome to this video tutorial on SOAP progress notes. Nurses and other healthcare providers use the SOAP note as a documentation method to write out notes in the patient’s chart. SOAP stands for subjective, objective, assessment, and plan. Let’s take a look at each of the four components so you can understand this neat and organized way of note-taking.

S

S is for “subjective,” or what the patient says about what they’re experiencing or feeling. It includes the patient’s complaints and concerns. In the patient’s own words—why they are here at the clinic or hospital. For example, “The patient complains of feeling achy all over her body,” or “The patient states a sore throat and chills started last night.” In this section, you want to describe the onset, location, frequency, intensity, duration, and what makes it better or worse. If this is the first time the patient is being seen, you also need to include the patient’s medical, surgical, family, and social history. Also current medications, allergies, smoking status, drug/alcohol use, and level of physical activity.

O

O is for “objective,” or what the nurse observes or measures from the patient. This would include vital signs, test results, facial expressions, and body language. For example, BP, pulse, temperature, weight, findings from a physical exam, and results from lab or diagnostic tests. Some examples from a physical exam include things such as, “The patient’s skin is red and hot to the touch,” or “The patient grimaced when he moved his right arm.” “The blood pressure reading is low and the heartbeat sounds fast and irregular.”

A

A is for “assessment” or “analysis.” This is the medical diagnosis or, in our case, the nursing diagnosis, in which the nurse identifies problems or issues that need to be addressed. They would include things such as, “The patient is at risk for a heart attack as evidenced by chest pain and clammy skin,” or “Risk for falls, related to right-sided paralysis.” The nursing diagnosis analysis step guides us to the next step of planning.

P

The P for “plan” is where the nurse is noting the chosen interventions that personalize the care of the patient. These interventions are specifically chosen to move the patient toward the desired outcomes or goals. These interventions need to be based on the patient’s specific needs and abilities. In order to be effective, they need to be realistic and measurable, so they can be evaluated. This may include medications, treatments, therapy, education, or referrals.

Example

Let’s take a look at an example of SOAP note-taking for a patient that recently had surgery.