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Examples of SOAP Notes in Nursing

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  • 0:00 What are SOAP Notes?
  • 0:45 What Does SOAP Stand For?
  • 2:49 Sample Scenario
  • 3:55 Lesson Summary
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Lesson Transcript
Instructor: Lynee Carter
From this lesson, you will learn why nurses use SOAP notes to write about patients, as well as what each section of the SOAP notes stand for along with specific examples.

What Are SOAP Notes?

Nurses may feel they are given a huge basket of dirty laundry to wash when taking care of patients. They are presented with a lot of different information that needs to be gathered and sorted through before carrying out specific interventions. The information also needs to be clearly documented so that other health providers can understand and do their part in caring for the patient.

Like separating dirty laundry from clean, SOAP notes are what nurses use to separate all the insignificant information about patients from significant information. It shows what is happening to patients in a neat and organized way. This makes it easier for other healthcare members to understand and care for patients more effectively.

nurse writing

What Does SOAP Stand For?

There are four components that form these notes that make up the acronym S-O-A-P:

S is for subjective, or what the patients say about their situation. It includes a patient's complaints, sensations or concerns. In most cases, it is the reason the patient came to see the doctor. Here are some examples:

  • The patient complained of a severe pain on the right side of his head.
  • The patient stated having a sore throat and chills.
  • The patient mentioned feeling itchy all over her body.
  • The patient was worried about not being able to sleep for three days.
  • The patient wanted to see the doctor for his annual physical.

O is for objective, or what the nurses 'observe' in the patients. It includes facial expressions, body language and test results. Nurses can conduct a physical examination where more data is obtained. Some examples include:

  • The patient grimaced when moving his right leg.
  • The patient avoided direct eye contact.
  • The patient's blood pressure reading was high.
  • The heartbeat sounds irregular.
  • The skin felt cool and clammy.

A is for analysis or assessment. Nurses make assumptions about what is going on with the patients based on the information they obtained. Although these assessments are not the medical diagnosis that health care providers make, they still identify important problems or issues that need to be addressed. Some examples include:

  • The patient is at risk for stroke.
  • The patient seems very anxious.
  • The patient is having difficulty breathing.
  • The wound looks like it is infected.
  • The patient did not have a physical last year.

P is for plan. Nurses make decisions about how to provide care based on the patient's specific needs and abilities. The interventions also have to be realistic and measurable so their effectiveness can be evaluated. This can include treatments, medications, education, and consults to other members of the healthcare team.

nurse planning

Sample Scenario

Let's see how the nurse would write a SOAP note in this scenario:

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