The Structure of a Standard SOAP Note

The Structure of a Standard SOAP Note

As mentioned a few moments ago, SOAP is an acronym. The letters S.O.A.P stand for Subjective, Objective, Assessment, and Plan, respectively.

1. S (Subjective)

Under the S (Subjective assessment) section of your SOAP note, you should collect subjective information. Subjective information is the information given by patients. This information is usually helpful in identifying the problem. However, it is referred to as subjective assessment because it is from personal views, feelings, experiences, and so on. There are three pieces of subjective information you should collect in this section of your SOAP note. The Chief Complaint (CC), the History of Present Illness (HPI), and the general patient history. The CC is the main problem the patient is complaining about. It could be a symptom, a previous diagnosis, or a condition. Examples of chief complaints include shortness of breath, reduced appetite, constant headaches, fever, and chest pain. When recording CC, it is important to be brief. HPI is collected in an elaborate manner. The information is collected by asking the patient to expand on their CC. The information collected under HPI includes an opening line stating the age, the sex, and the CC of the patient. It also includes the onset, the location, the duration, the characterization, the radiation, and the severity of the CC. When collecting HPI information, it is important to focus on quality rather than quantity. General patient history is the last piece of information collected under the subjective assessment section of the SOAP note. The general patient history that needs to be collected in a typical SOAP note includes medical history (present or current conditions), surgical history, family history, and social history. The personal history collected needs to include current medication.

2. O (Objective)

Under the O (Objective assessment) section of your SOAP note, you need to collect objective data. The objective data you need to collect includes General Survey, Vital Signs, Range of Motions, and Laboratory Results. A standard SOAP note objective assessment section will have spaces for entering all types of objective data including HEENT, special tests, imaging results, laboratory data, physical exam findings, abdominal, lymph, and circulation data. This section will also have a subsection for the Review of Systems (ROS). This is often a list of questions designed to help clinicians to uncover symptoms perhaps not mentioned by a patient. The questions usually review the general body system, the musculoskeletal system, and the gastrointestinal system. Questions under the general body system sub subsection can help to uncover symptoms such as reduced appetite, weight loss and so on. Questions under the musculoskeletal system sub subsection can help to uncover symptoms such as reduced range of motion and toe pain. Lastly, questions under the gastrointestinal system sub subsection can help to reveal symptoms such as stomach cramps and abdominal pain. When writing the objective assessment section of your SOAP note, try to be as objective as possible. You should also try to be as clear as possible. Of course, you should also try to capture as many details as possible but you should not be verbose.

3. A (Assessment)

Under the A (Assessment) section of your SOAP note, you need to detail the working diagnosis based on the information you have captured in the S (Subjective) and O (Objective) sections of your SOAP note. In other words, in this section of your SOAP note, you need to synthesize the data you have gathered so far to complete your work. The best way to approach this section of the SOAP note is to assess the status of the patient by analyzing the problem, analyzing the objective data, and diagnosing the problem. In case of a repeat visit, it is in this section that a clinician is supposed to capture the changes to the objective and subjective information in the patient. This section typically includes two key subsections — working diagnosis and differential diagnosis. The working diagnosis subsection is where you should list the problems beginning with the most important one. In this case, the problem is the diagnosis. In other words, it is what is affecting the patient based on the information you have collected. The most important diagnosis is the primary diagnosis. It should be stated in words alongside its ICD-10 code. The second subsection is the differential diagnosis section. It is in this section that you should list other possible diagnoses. You should list them from the most likely one to the one that is least likely. You should also detail your thought process. It is in this subsection that you should fully explain your decision-making process. And the best way to do this is to state a differential diagnosis and then to detail the rationale behind including the diagnosis. Do this for all your differential diagnoses. When providing the rationale behind a diagnosis, you should do it using evidence from credible nursing or medical literature sources. And don’t forget to mention the signs or symptoms in the subjective or objective assessment sections that led to each diagnosis.

4. P (Plan)

This is the last section of a SOAP note. It is perhaps the most important part of a SOAP note. It is in this part of your SOAP note that you should document the interventions you have identified for the treatment of the diagnosed problem. This section has space for additional consultation and testing. However, its main purpose is to document the interventions or steps to be taken to assist the patient. When writing this section of the paper, you will typically include four subsections: lab, therapy needed, consults, and patient education. Under the lab subsection, you should note any tests you want to be carried out at the laboratory. You should state the reason or rationale for each test. The best way to write the tests you want is by starting from the most important one to the least important one. The tests should be listed next to the related diagnosis. What should follow in case of a negative or positive test should also be written next to each test. Under the therapy needed subsection, you should indicate the interventions and medications needed to address the diagnosis or diagnoses. The interventions and medications should be supported by evidence from credible nursing literature. Under the consult subsection, you should indicate if the patient needs more advanced care. The information should include a reference to be contacted and how soon. The patient education subsection is the last subsection of a typical SOAP note. You should include information on how you will conduct patient education. The patient education information should consider the customer's cultural and linguistic orientation. As you can see from the information above, the structure of a standard SOAP note is pretty complicated as you can see. It has several sections and subsections that are very important and that need to be written accurately and concisely.

SOAP Note Template for Nursing Students

Soap Note Template for Nurses

• Date:___________________________________
• Written by:____________________________
• Reliability:______________________________

SUBJECTIVE ASSESSMENT

• Chief Complaint:______________________________
• HPI: (Use SLIDTA)_____________________________
• Medical history:________________________________
• Surgical history:________________________________
• Family history:_________________________________
• Social history:__________________________________

OBJECTIVE

• Vital signs:_______________________________________
• Recent Labs:______________________________________
• General Survey:___________________________________
• Physical Exam:____________________________________
• Lung:____________________________________________
• Heart:____________________________________________

ASSESSMENT

• Working diagnosis:________________________________
• Differential diagnoses:______________________________

PLAN

• Medications: _______________________________________
• Labs: _____________________________________________
• Diagnostics:________________________________________
• Consults:__________________________________________
• Patient Education:__________________________________

References

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