When I explain to new nurse practitioners or nurse practitioner students how to write a SOAP note, I’m not talking about the substance that makes you squeaky clean! The term SOAP is an acronym used to explain the basic components of a typical chart note. When a nurse practitioner evaluates a patient, that APRN needs to document the findings and plan of care. A SOAP note is an easy way to organize information to create a complete chart note. This article will discuss the components of a chart note and also some tips on how to write a SOAP note.
SOAP is a standard method of recording patient information among nurse practitioners and healthcare providers. There are four basic components of a SOAP note: Subjective, Objective, Assessment, and Plan. A SOAP note is standard across all types of chart notes and can be used in any area of healthcare. We will break down each component of a SOAP note and explain how to write a SOAP note.
Before the nurse practitioner starts to write a SOAP note, they need to ensure they add basic identifying information for the patients. For example, begin by documenting the patient’s identifying information, including their name, date of birth, age, gender.
Objective: Information that is measured or observed.
Assessment: Summary of subjective and objective data
Plan: Plan of care created by the healthcare provider
We now further discuss each component of a SOAP note.
The subjective part of a SOAP note refers to the patient’s chief complaint, history of present illness, past medical history, and review of systems. The subjective section includes what the patient reports (aka the subjective information). If the patient is unable to provide details (i.e. a child or unresponsive patient), the nurse practitioner can ask a caregiver, family member, bystander, or even other healthcare providers (EMS) for information.
To start the subjective portion, introduce the patient and their reason for seeking medical attention (aka chief complaint). For example, “Patient presents with complaints of an ongoing cough and shortness of breath.”
Then, document the patient’s history of the present illness. This includes how the patient describes the symptoms, the onset and duration of symptoms, past treatment, etc.
When writing a SOAP note, I like to use the OLDCARTS acronym when describing the history of present illness.
O- Onset (acute or gradual)
A- Aggravating factors
R- Relieving factors
T- Treatments (and response)
S- Severity or Symptoms
Utilizing the OLDCARTS acronym helps remind me what questions to ask when obtaining the history of present illness. It also helps to document information in a systematic way.
Here is an example of a history of present illness, “Patient presents to the clinic for complaints of right forearm pain. Pain started after the patient slipped on the ice and landed on right forearm. Reports severe, sharp pain to mid forearm. Worse with any movement of the forearm. Improves with rest. Taken Tylenol is minimal improvement.”
As you will see, writing as SOAP note creates a clear layout of information. This history of present illness includes a lot of information but did not take long to write (helpful for time management as a nurse practitioner).
The next component of the subjective section is the past medical history. This includes medical conditions, surgical history, allergies, and home medications. Again, most of this is reported by the patient and therefore falls under the subjective section.
The review of systems (ROS) is the next component in the subjective section. Review of systems covers the 14 systems of the human body.
These systems include:
Again, the ROS is the information given by the patient. It is a way to obtain and document any complaints the patient has within the body systems. For example, cardiovascular ROS may include “Denies chest pain, shortness of breath, or palpitations. No peripheral edema.” This gives a look at what signs or symptoms the patient presents with.
Remember the subjective section includes information given by the “subject” aka the patient. Utilize these tips for the subjective portion when you write a SOAP note.
The objective section of a SOAP note refers to the objective information that the nurse practitioner observes. The objective section is a description of the patient’s physical exam findings and objective data that can be measured or observed. The information is generally factual because it can be quantified. The objective components include physical exam, vital signs, and diagnostic data (lab tests, imaging studies, etc.).
When you write a SOAP note, vital signs should go under the objective section. Document the patient’s vital signs, including blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, height, weight, and pain level.
Then, document the results of the physical exam utilizing the body systems. Make sure to include normal and abnormal findings. There are 11 sections of a physical exam which include:
For example, a respiratory exam may include: “Respirations even and unlabored, chest expansion symmetrical. Breath sounds clear in all lobes, no wheezes, crackles, or adventitious breath sounds.” Again, when you write a SOAP note, we want the information to be easily documented to allow for accuracy and easy readability.
Charting Tip: Remember with the new Evaluation and Management changes, we no longer need to make sure we address a certain number of review of system components or physical exam topics. Writing a SOAP note should satisfy a medically necessary ROS and physical exam. Deciding which of the systems to address or document is at the discretion of the nurse practitioner (whatever the feel is medically necessary). Click to find out more information about The NP Charting School’s Billing and Coding Course.
Next, document any lab tests or imaging studies that were ordered, including the results (or show results pending). For example, “A chest x-ray shows consolidation in the left lower lobe consistent with pneumonia.”
It also helps to document who interpreted the results. For example, if the nurse practitioner evaluated the EKG, make sure to add that when you write a SOAP note. If a radiologist read a knee X-ray, acknowledge this when you write a SOAP note.
Remember the objective section is for the information and data that is observed or measured. This creates an easy and systematized way to write a SOAP note.
The assessment section of a SOAP note is where the healthcare provider documents their impression of the patient’s condition. The assessment section includes a summary of the subjective and objective data, along with any additional information, such as the patient’s pertinent past medical history. The nurse practitioner utilizes medical decision making and completes to a conclusion of the patient’s condition. The assessment section includes any relevant diagnoses and may also include differential diagnosis.
To start, summarize the patient’s current condition and list any diagnoses. For example, “The patient is a 55-year-old male with a history of smoking who presents with symptoms of cough and shortness of breath. Based on the physical exam and imaging studies, the patient is diagnosed with pneumonia.”
Next, document any additional information that may be relevant to the patient’s condition, such as comorbidities or risk factors. For example, “The patient has a history of chronic obstructive pulmonary disease (COPD) and is a current smoker, which puts him at increased risk for respiratory infections.”
If the diagnoses is not clear or differential diagnoses are considered, the nurse practitioner can add this into the assessment section. The nurse practitioner can utilize this portion to add any thoughts or interpretation of the patient’s exam/diagnostic tests.
Charting tips: Often I will simplify the assessment section. If the condition is straightforward, I simply list the diagnoses. I also don’t always list differential diagnoses. An upper respiratory illness is pretty straight forward so I don’t add differential diagnoses.
However, I would add differential diagnoses for a patient who had abdominal pain and required further evaluation for definitive diagnosis. This is where I would explain pertinent positives and negatives to include or exclude possible diagnoses.
With more complex patients, I often combine the assessment and plan sections. I find that my chart note is redundant if I am writing the assessment and then adding much of the same phrases in the plan.
The plan section of a SOAP note is where the nurse practitioner documents the treatment plan for the patient. There is not a specific outline for the plan but may include some of the following topics:
Any refills, dose/frequency changes, new medications, recommendation to take OTC medications, etc. should be listed in the plan. To start, list the medications that were prescribed and their dosages. For example, “The patient is prescribed 500mg of amoxicillin three times daily for 10 days.”
Sometimes the nurse practitioner can pull these prescriptions from the electronic medical record to make it easier to write a SOAP note. Make sure to add any side effects or adverse reactions that were educated to the patient.
This includes any instructions given to the patient. This may include changes in diet, activity level, or other non pharmacological treatments. If the patient was evaluated for an orthopedic complaint, make sure to add instructions such as “Ice and elevate extremity. Avoid strenuous activity.”
Or perhaps the patient has Type 2 diabetes. Maybe as the nurse practitioner you would add “Discussed non pharmacological treatment such as low-carb, well balanced diet and increase in physical activity.”
Document any referrals that were made, such as to a specialist or services. For example, “The patient is referred to a pulmonologist for further evaluation and treatment of COPD.”
Maybe the nurse practitioner would like the patient to follow-up in one month for a recheck. Or maybe the nurse practitioner would like the patient to follow-up with cardiology. If there are any specific follow-up instructions be sure to add in the plan section. For example, “Follow up immediately for any chest pain or shortness of breath.” Or, “Follow-up for worsening or persistent symptoms.
Charting tips: The plan section is for the nurse practitioner to list out the plan of care for the patient. Smart/dot phrases can be very useful in this section. If you find yourself frequently typing common plan of care instructions, common side effects of medications, when to follow-up, etc. create smart phrases that can easily be pulled into the SOAP note. Adding the above listed components will ensure the nurse practitioner can write a SOAP note that encompasses the instructions for the patient.
Nurse practitioners can write a SOAP note to create a systematic and simplified chart note. Nurse practitioners can ensure they create a through yet easy to read SOAP note. If you are a nurse practitioner student or new nurse practitioner, refer to this article when you begin documenting. If it feels overwhelming, look at other health provider’s documentation and you will begin to see the flow of a SOAP note.
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