Help with SOAP notes

VickyRN, MSN, DNP, RN · Oct 6, 2005

Hey guys..Im new to this site. Im a second year nursing student in a 2 year program. Im in my second week of clinical and my instructor added a SOAP note for us to write for each day. I understand the subjective and objective date but I have wicked trouble with the assessment and planning part. Can someone help me with this....maybe by sending me an example of one or just anything cuz im stressing over this. THanks
AMy

Perhaps these resources may be of assistance to you :)

http://www.medicalassistant.net/soap_example.htm

http://www.vnh.org/SickcallScreeners/SOAPNotes2.html

http://www.hmc.psu.edu/cpc/courses/1styear/soapexamples.pdf

http://www.maexamhelp.com/soap_note.htm

VickyRN, MSN, DNP, RN · Oct 6, 2005

SOAP charting is used to record progress notes in relation to problem-focused charting. SOAP notes may be used by all members of the interdisciplinary health care team. The narrative notes are specifically related to a problem list (a problem which has already been identified or a new problem which you have just identified and activated) and are numbered and titled accordingly. For example, a reference made to a client's surgical incision would be preceded by the number of the problem (from the problem list) and the name of the problem. In amny institutions, the "problems" are nursing diagnoses.

Subjective data describe the client's problem as the client sees it; it is neither measurable nor observable. Subjective data must be related to the nurse by the client.

Objective data are those items of information that are measurable or observable by another person - for example, a rash, edema, wound edges, or laboratory findings.

In the assessment component of the note, conclusions are summarized on the basis of the data presented.

The plan outlines actions that will address any identified problem. The plan, for example, may include further diagnostic tests, nursing interventions, or client teaching. Often the plan is simply to continue the previously outlined plan.

Example:

Problem: #1 Acute Pain r/t surgical incision

Progress Notes:

S = States discomfort in right hip.

O = Grimaces with movement to right side. Requests prescribed pain medication (Vicodin ES) every four hours.

A = No change.

P = Continue pain meds PRN.

As you can see, this is a very abbreviated version of care-planning and you use the nursing process.