Soap in Nursing

SOAP in Nursing: A Detailed Guide

SOAP is an acronym for Subjective, Objective, Assessment, and Plan—a standardized method of documenting and communicating patient care in healthcare settings. In nursing, SOAP notes are essential for clear, concise, and accurate patient records that support continuity of care.

1. Purpose of SOAP Notes in Nursing

SOAP notes help nurses:

• Organize patient data logically and consistently.

• Improve communication among healthcare team members.

• Support clinical decision-making through structured documentation.

• Ensure legal and professional compliance with nursing standards.

• Track patient progress over time for evaluation of care.

2. Components of SOAP

S — Subjective

• Definition: The patient’s personal experience and perspective, expressed in their own words or through caregiver reports.

• Sources: Direct quotes, patient-reported symptoms, feelings, concerns, and history.

• Example in Nursing:

  • “I feel dizzy when I stand up,” reports the patient.

  • “My pain is about 7 out of 10 and it’s sharp in my lower back.”

O — Objective

• Definition: Observable, measurable, and factual data collected during the nurse’s assessment.

• Sources: Vital signs, physical exam findings, diagnostic results, wound measurements, observed behaviors.

• Example in Nursing:

  • BP 148/92 mmHg, HR 96 bpm, Temp 37.8°C.

  • Patient ambulated 10 meters with assistance; unsteady gait noted.

A — Assessment

• Definition: The nurse’s professional interpretation or clinical judgment based on the subjective and objective data.

• Purpose: To identify the nursing diagnosis, problem status, or patient’s condition.

• Example in Nursing:

  • Orthostatic hypotension likely related to dehydration.

  • Acute pain related to post-operative incision.

P — Plan

• Definition: The nurse’s plan of action to address identified problems or needs.

• Includes: Nursing interventions, referrals, education, follow-up monitoring, or physician notifications.

• Example in Nursing:

  • Encourage oral fluid intake of 2 L/day.

  • Administer prescribed analgesic before physical therapy.

  • Monitor BP every 4 hours; report systolic < 100 mmHg.

3. Advantages of SOAP in Nursing

• Promotes clarity and focus in documentation.

• Facilitates collaborative care across the healthcare team.

• Enables tracking of patient outcomes systematically.

• Meets legal and accreditation documentation standards.

4. Common Mistakes to Avoid

• Mixing subjective and objective data in the wrong section.

• Using vague or non-specific language.

• Omitting relevant details.

• Failing to update the plan based on new findings.

5. SOAP Note Example in Nursing

Patient: John Doe, 65 y/o, admitted with pneumonia.

• S: “I’m still short of breath even when I’m sitting. My cough is keeping me awake.”

• O: RR 26 breaths/min; SpO₂ 90% on room air; crackles heard in right lower lung lobe; productive cough with thick yellow sputum.

• A: Impaired gas exchange related to lung infection.

• P: Administer O₂ via nasal cannula at 2 L/min; encourage deep breathing exercises every 2 hours; monitor SpO₂; notify physician if < 88%.

6. Tips for Effective SOAP Note Writing

• Use clear, concise, and professional language.

• Record information promptly after assessment.

• Stick to facts and observations—avoid assumptions in Objective.

• Update the Plan as patient condition changes.

• When quoting a patient, use quotation marks.

7. Relation to Nursing Process

SOAP aligns naturally with the ADPIE nursing process:

• S & O → Data collection (Assessment stage)

• A → Nursing diagnosis

• P → Planning interventions

This makes SOAP a practical documentation format for implementing the nursing process in daily clinical practice.