Documentation book/Soap notes

have no book recommendations, but do have two websites about soap notes:

http://www.medicalassistant.net/soap_note.htm - writing soap notes. includes links to sample soap notes at the bottom of the page.

http://en.wikipedia.org/wiki/soap_note - soap note

first of all, let me clarify for you that the act of documenting, or charting, cannot land you in jail and it is erroneous to refer to the act of charting as being legal or illegal. there are rules to the way a facility may want its employees to document, so they have right and wrong ways for its nurses to chart. soap charting is a type of problem oriented charting method where the following information should be documented for each of the following parts of the note:

• subjective data: chief complaint or other information the patient or family members tell you
  
• objective data: factual, measurable data, such as observable signs and symptoms, vital signs, or test values
  
• assessment data: conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses
  
• plan: strategy for relieving the patient's problems, including short and long term actions
  
  • all of the above comes from page 676 of portable rn: the all-in-one nursing reference, third edition, published by lippincott, williams & wilkins, 2007
    

as you can see, s (subjective) data and o (objective) data each have their own specific place in the soap charting method, so, no they should not be combined together when writing a soap note. they should be distinctively separate from each other as in the example below from page 677 of the above reference: