Mandatory SOAP notes

[Do_Good]

8 months ago our new DON mandated SOAP notes. We were recently told that part of our yearly review will include chart reviews of our notes. I don't believe this type of note fits every situation.

Does anyone else have to write SOAP notes?

[BD-RN, BSN, RN]

One hospital I worked at preferred we right DAR noted (Data, Action, Response). These were not brought up in our evaluations, but they might be in a chart audit. Most places I've worked required a note per shift. I kind of like writing notes. They are where I can explain any assessment changes, what I did with them, etc. I can summarize my day, and track my patients' progress.

[akulahawkRN, ADN, RN, EMT-P]

Once you get the hang of writing SOAP notes, they're actually not that difficult/hard to do. They do, however, take a little time. Probably the hardest part of writing a SOAP note is knowing what "stuff" belongs in what section of the note so that you don't "double chart" something. Until you learn how to make a SOAP note to be essentially "plug and play" your charting time likely won't be short...