SOAP Notes

  1. howdy folks!

    anybody know of a good resource for writing complete, accurate, thorough SOAP notes???

    We are expected to do them but nobody has really taught us...

    Thanks for any input you might provide...
    Sarah
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  2. 7 Comments

  3. by   GPatty
    S=subjective data collected from the patient. Things they say is/are going on with them.
    EX: fever, stomach pain.....

    O=objective data that is "provable".
    EX: You take the temp. Is it high? Normal? Is their stomach distended? Hard or soft?

    A=assessment is an evaluation of the persons disease or problem based on subjective and objective data.

    P=planning is the stragety designed to achieve the care desired for this particular patient.

    Hope this helps you out!
  4. by   beaRNwhenIgroUP
    Thanks Julie...what i am really having problems understanding ishow much info we put under subjective and objective?

    if we are doing a complete health history and under musculoskeletal they say they have never had any problem, do i say pt. denies joint pain, stiffness, change in range of motion, etc... all of the questions i ask him / her; OR do i just not mention anything at all since they have no problems there?

    or is there some blanket statement that will say the pt. has no problems w/in this system??? e.g. pt denies any changes or problems w/ (blank) system

    i hope i don't seem like too much of a ding-dong

    thanks
    sarah
  5. by   Love-A-Nurse
    hi bea. look for a pm from me.
  6. by   roud123
    I think you only chart abnormals (at minnium)
    Unless it is r/t the diagnosis or plan of care
  7. by   LPN & EMT-CT
    Originally posted by beaRNwhenIgroUP
    howdy folks!

    anybody know of a good resource for writing complete, accurate, thorough SOAP notes???

    We are expected to do them but nobody has really taught us...

    Thanks for any input you might provide...
    Sarah
    Try to get your hands on a nursing dx book, usually from Barnes & Noble or Books A Million, they usually have a great nursing section.
    Hope this helps.
  8. by   beaRNwhenIgroUP
    [FONT=century gothic]you guys are great - i think i'm starting to get it - maybe i was just having a blonde moment....

    it's been a REALLY LOOOONNNNGGGG week!

    Thanks again,
    Sarah
  9. by   globalRN
    hi Sarah:

    Bates Guide to Physical Examination and History Taking is a classic
    text.
    Your school may have a text they recommend for nursing diagnoses(NANDA is popular).

    S=Say/Said by patient
    O=Observed or Objective(as in measured)
    A=your diagnosis
    P=plan of treatment

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