How to write a soap note: Latest best guide


How to write a soap note

The first question that comes to your mind as a fresher nursing student is what a soap note is. Well, it’s not bad to not know or have an idea of what it means. While it might seem a like a walk in the park to some it is like climbing Mt. Everest for others. How to write a soap note:

Soap is an acronym for subjective, objective, assessment, and plan. The notes are to help the nurses to have a well-structured note for continuity of treatment. The soap notes are very vital in the industry. Well he has compiled all you need to know about soap notes for all academic levels

Before settling down to write a soap note, all details that need to be captured must be subjective, the objective can be assessed and has a plan.

Writing a soap note

Our team has put together a number of tips to help you write award-winning soap notes. Below are some of the tips to consider while writing a soap note. The acronyms are to be considered:

  • S – Subjective
  • O – objective
  • A – assessment
  • P – plan

Even though the content might vary according to the differences in the hospital. The notes are to be written under the subheading in the acronym. Below is a breakdown of the acronyms and how each content can be framed which is the acceptable soap format

Subjective: In this section, the client’s subjective information is recorded. These include how the client feels and experiences. However, the information could be given by the clients or the immediate significant other.

Objective: This is the recording of the objective data on the client. This section must contain all the fundamental information on the client’s health.

Assessment: This is the recording of the information about the patient’s diagnosis. With the dispensation of the nurse’s knowledge. They record a thorough assessment with details of diagnosis with attached evidence.

Plan: This is the planning of the future action as per the treatment administered. This section also allows for further amendments as per the clinicians’ assessment.

To have an effective and comprehensive soap note. You will need enough time to write the notes after a session with a client. This will help in capturing enough details and enough narration to be able to come up with a proper treatment plan.

Tips for completing SOAP notes

  1. The language in the notes should be professional

Vividly describe the exact situation the client was in or the nonverbal cues the client presented. The use of reported speech is encouraged.

  1. Maintaining specificity

Avoid using a number of amorphous words. Instead, be specific with the details.

  1. Effectiveness

The soap notes must attain the art of effectiveness. This is to deliver the intended subject.

  1. Accuracy

Soap notes must be clear and communicate the exact details.

  1. Communicable

The soap notes must communicate the details that are intended.

Tips for writing mental health soap notes

Mental health is on a current global watch. Taking these notes will are very vital. The details taken down by the attending nurse will determine the health care and the treatment plan to be administered. There is a well-drawn framework in the patient’s case notes that will help in improving the quality of treatment.

The four acronyms when considered can help physicians to create a well-drafted and solution-based treatment plan. I can also be used as a way of communication between the nurses as they seek more clarity and any change of course in the treatment plan. Our team has soap note examples of mental health ready for sharing at your beck and call.

Psychiatric soap note example

  1. Subjective

Mr. Rich states that he is very ‘sober and okay’. He says he has felt much better and relieved as much as he still has episodes of emotional breakdown. He states that his lack of sleep is causing him anxiety and restlessness.

  1. Objective

Mr. Rich has puffy eyes and is restless. His sleep has not improved and keeps having anxiety attacks. However, he is really trying to get the best out of it.

  1. Assessment

Mr. Rich has (General Anxiety Disorder) GAD

  1. Plan

Mr. Rich will continue practicing reality checks, working on his triggers, and being realistic. There will be a call-back check by Tuesday next week.

Sample soap notes mental health

  1. Subjective Complaint

‘I am at a point in my life and I feel like I am giving up’. I can’t understand why I am living in such a state.   Don’t know how to make them see what I can do.”

  1. Objective Section

Pennine is pacing up and down. She is frustrated and furious. Her eyes are swollen with tears almost rolling. More diagnoses can be sighted.

  1. Assessment of Progress

Pennina is now able to understand why she feels the way she does. She has been able to dig deeper and has since found the root cause of many happenings. She has since found coping with some of the situations.

  1. Plans for Next Session

We booked up another physical appointment. Pennine has agreed to go with some strategies that will help us not to feel overwhelmed.

Soap notes assessment

Writing assessment notes is very vital because it encompasses the subjective and objective aspects of the notes.  The notes are written professionally by the nurses seeking to interpret the presenting issues of the clients.

Clinical knowledge is applied at this stage. All the presenting issues are assessed and a proper diagnosis and treatment plan can be implemented. This section may indicate the exact situations in the subjective and the objective.

During the taking down of soap notes, the general situations and conditions might not get to the assessment as they are handled between the objective and the subjective. However, some situations that look severe are taken to the assessment stage.

The notes in the assessment are being used in the subsequent planned visits for review. The assessment is used to review the current position and the previous position to establish change. This can also be used to either stick or change the treatment plan.

The progress of the client can also be monitored using the assessment. Well, there are some phrases that should be included. These are some of the things that should be included:

  • Include regression of the content
  • Have a climbing graph of the patient’s progress
  • Avoid repetition in the sentences

Soap notes example for Psychotherapist

Below is a soap notes sample for psychotherapists.

  1. Subjective

Dorothy reports that she is ‘having panic attacks’ making her feel awful as she goes around her normal day-to-day activities. She says she breathes and holds in for 4 seconds to help her numb the panic whenever it occurs.

  1. Objective

Dorothy came in for the session. She appeared a little bit settled and easy. She explained how the week has been and how she has managed the attacks. By now she is able to put to task what the triggers are.

  1. Assessment

Dorothy came in with a more calm spirit. Her heart palpitations were now more normal as she reported. Today Dorothy is able to speak in a well-coordinated speech. There were no signs of panic, anxiety, or any delusional cues.

  1. Plan

Dorothy’s next appointment is at 11 am next week on Wednesday. Dorothy will continue with the coping tactics and the treatment plan prescribed.

Above is a soap note example that has the four acronyms broken down into details. Reach out to our team order for an academically approved soap note template at bestnursingwritingservices.com.

In summary

Writing soap notes can be an easy exercise when you are fully armed with the content of the acronyms. Each soap notes varies with the content fed depending on the presented case and the clinical departments.

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