When writing a nursing SOAP note, document the patient's chief complaint, objective findings from a physical examination or medical tests, an assessment of what is wrong with the patient, and a care plan, states Education Portal. The SOAP note should be signed, dated and added to the patient’s medical record.
Begin the note by documenting the patient’s chief complaint, as well as the onset, duration and severity of all other symptoms, explains EMRSoap. Include any treatments received for these symptoms and how effective those treatments have been.
Secondly, document all the objective facts about the patient’s condition. This includes the patient’s vital signs and a physical examination, but can also include laboratory or test results. Next, assess the patient’s condition. While nurses are not permitted to diagnose a patient, they can still identify problems and document assumptions about what may be wrong with the patient. For example, although prohibited from diagnosing a patient with ADHD, a nurse may document that the patient seems to have problems focusing and appears hyperactive, according to Education Portal.
Finally, conclude the SOAP note with a treatment plan. Include any medications that a physician might consider prescribing, tests or referrals that may be scheduled, and provide the patient with education that can help treat the condition, reports EMRSoap. Sign and date the note, and ensure it is saved within the patient’s medical record.