5 Tips and Tricks for Writing Successful Soap Nursing Notes
By Sarah Stasik, Contributor
The SOAP note is almost half a century old and is still used by many healthcare facilities because of its usefulness in ensuring easy-to-understand, comprehensive documentation.You probably already know the basic Subjective, Objective, Assessment and Plan structure, but check out some tips for SOAP nursing notes from the experts below. Then, visit TravelNursing.com to discover healthcare jobs in locations across the country where you can put your charting and patient care skills to work.
5 tips for writing strong nursing SOAP notes
1. Don't assume the first complaint is the chief complaint
The Subjective section of SOAP notes is supposed to provide context for later sections,so if nurses record a chief complaint that is not aligned with the Assessment and Plan, the entire note may read off kilter. Authors Valerie Lew and Sassan Ghassemzadeh caution nurses against assuming the first reported complaint is the chief complaint. Instead, they encourage clinicians to have patients share information about all their complains to suss out what might be the primary issue.
2. Double check your EMR entries for errors
Nursing SOAP notes may seem like second nature if you're an experienced RN, but make sure you take time to proof your work. Something as simple as a typo can change the entire meaning of your note, and there have been cases where nurses wrote pristine SOAP notes in the wrong patient's online chart. A few minutes of extra care can go a long way to reducing these types of errors.
3. Connect diagnosis with intervention
Veronica Anzalone, RN, has 16 years of healthcare experience. She's reviewed a lot of charts from many perspectives, and says it's important for nurses to chart with reimbursement in mind."
The last seven years of my career have been spent working within the healthcare revenue cycle," says Anzalone, "including five years reviewing medical records for medical necessity and coding appeals. In many instances, a case was made for appropriate reimbursement because the nurses caring for the patient whose claim was in question, carefully connected their nursing interventions and rationales to their assessment."
4. Don't make assumptions about the person reading your notes
Anzalone also says nurses shouldn't make assumptions about who might read charts in the future. It's not always another clinician; lawyers, reimbursement decision makers and others may read nursing SOAP notes."
With my experience in retrospective chart review, detail matters," says Anzalone. "As we are taught in school: if it is not documented, it did not happen. A nurse should not take for granted that the person reading their note will know that the standard of care has been met."
5. Limit the Assessment portion of soap nursing notes to appropriate information
Remember that nursing SOAP notes should be comprehensive, but concise. That requires including the appropriate information in each section, but leaving out extraneous notes or opinions that don't belong there. For example, the Assessment should only include notes regarding the diagnoses being managed and the overall progress of the patient.
The ability to write coherent, accurate and comprehensive SOAP nursing notes helps nurses ensure continuity and safety of patient care.