Even though SOAP notes are a straightforward method for keeping track of your progress, having a sample or template to follow is still useful. To help you create more thorough and succinct SOAP notes, we’ve taken the time to compile some examples and templates.
Although SOAP notes provide guidance on what information is needed and how to format any progress notes, it can be helpful to have a sample in front of you. Because of this, we’ve taken the time to compile some examples and SOAP note templates that we believe will enable you to write SOAP notes that are both more detailed and succinct.
What you need to know about writing a progress note (Nursing School Lesson)
Elements to include in a nursing progress note
The best practice when writing nursing progress notes is to be as specific as you can This aids in giving the other healthcare professionals an accurate and beneficial context. The following is a list of some components you might want to include in your nursing progress note:
What is a nursing progress note?
The records that nurses and doctors keep while a patient is hospitalized are called nursing progress notes. Because nurses frequently spend the most time with patients, they can add special information about the patient’s care and the patient’s progress toward recovery.
These notes enable healthcare providers to maintain a record of the treatments and medications a patient has received and ensure that the patient’s medical records are as current as possible. Progress notes frequently assist medical professionals in developing revised care plans as patients’ conditions change.
How to write a nursing progress note
When writing nursing progress notes, many medical professionals employ the SOAPI method. SOAPI stands for subjective, objective, assessment, plan and interventions. The steps to writing a nursing progress note using the SOAPI method are listed below:
1. Gather subjective evidence
Begin your nursing progress note by asking the patient for information after writing down the date, time, and both your name and theirs. This information is probably subjective and constrained by the expertise and viewpoint of the patient. Patients’ concerns, the severity of their pain, and the reason for their visit are all considered to be subjective evidence. Consider inquiring about your patient’s health from any family members or friends who are present when appropriate.
Act with empathy and use active listening techniques to take note of your patients’ concerns and demonstrate your interest in their well-being.
2. Record objective information
Obtain objective information to include in your progress note after speaking with the patient and hearing their perspective. Information like the patient’s vital signs, discernible symptoms, and the outcomes of any tests or bloodwork that you or the doctor ordered are included in this. The patient’s subjective information is frequently supported by objective information, which also helps put their concerns in perspective and helps determine the patient’s diagnosis.
3. Record your assessment
Using the patient’s symptoms and objective data, you and the patient’s primary care physician should draw conclusions about the patient’s condition in this section. Your evaluation also takes into account any medications the patient’s doctor prescribed, as well as their reaction. Try to identify any changes in the patient’s demeanor, outlook, or symptoms since their admission.
4. Detail a care plan
Any course of action you and the doctor intend to take for the patient’s benefit is included in the care plan section of your nursing progress note. An upcoming MRI scan for the patient, for instance, could be mentioned in the progress note. Detailing any pertinent information regarding the patient’s response to the care plan is also crucial. For instance, note this in the progress note if both the patient and you recommend they return for a checkup appointment but they decline.
5. Include your interventions
Your nursing progress note’s interventions section can contain a wide range of information. This part of your progress note primarily includes any additional information regarding the treatment the patient received during your shift. Include as much information as you can about the patient’s requests, the times you gave them medication, and any other observations you have about them.
Nursing progress note example
You might find it helpful to think about a sample nursing progress note as you practice writing them. This is what a nursing progress note may report:
Time: 5:36 pm
Patient name: Avery Kane
Nurse on duty: Mary Ann Merjos
Avery Kane, a 24-year-old woman, has excruciating stomach pain. The patient is alert and requesting pain medication. Miss Kane rates her level of discomfort as seven. Her brother, who brought her in, told us that Miss Kane had been queasy earlier that day and had refused to eat anything. The right side of her stomach is where the pain is the worst, and when Miss Kane first saw her, she said the pain came on suddenly.
Miss Kanes blood pressure is 110/70, her heart rate is 105, and her body temperature is 101F. Reduced breath sounds, severe pain, and tenderness in the lower right quadrant of her abdomen are all present in this woman.
We determine after speaking with the attending physician that Miss Kane has appendicitis and requires immediate surgery to have it removed. The patient is compliant and receptive to this diagnosis.
So Miss Kane won’t have to come back to have the stitches removed, the surgeons intend to use dissolvable stitches. We advise her to wear loose-fitting clothing and avoid strenuous activities while receiving outpatient care. As the patient recovers at home, we will call to check in.
We expect to discharge Miss Kane tomorrow morning.
Tips for writing a nursing progress note
You should take into account the following advice when writing your own nursing progress notes:
Ask for directions
While many nurses and doctors create nursing progress notes using the SOPAI method, some hospitals and clinics may have their own templates or procedures. Ask your supervisor how they expect you to write and arrange your progress notes when you start a new job.
It’s crucial to be as impartial as you can when penning your progress notes. Try to only include facts and observations. This keeps your progress reports up-to-date and available to anyone who might need to consult them.
Add details later
Many healthcare professionals take notes about the patient while speaking with them and then return to the progress note later to add details. It’s crucial to complete your notes for one patient before seeing another so that you can recall more specifics about your visit. If you can’t finish your notes before seeing another patient, try to at least capture the most crucial information.
While detailed notes are advantageous, make an effort to keep them brief as well. Only include pertinent information in the progress note and endeavor to be as descriptive as possible in order to keep your reports succinct. This enables other medical specialists to quickly review your progress note. Additionally, it cuts down on the time you spend taking notes.
Write end-of-day summaries
It might be necessary to include a day-end summary of the care some patients received and other information. This makes it easier for those working the following shift to monitor the progress of your patients. The chance to review your notes for the day and address any changes that need to be made to your nursing progress notes is provided by end-of-day summaries.
Read other nursing progress notes
When writing nursing progress notes, the majority of medical professionals use their own voices and writing styles. Consider reading other professionals’ notes to compare your style to theirs after learning the format that your supervisor prefers. In some cases, it might motivate you to make improvements to the way you write your own notes. This helpful study technique also makes nursing progress notes more familiar to you.
How do you write a nursing progress note?
- Gather subjective evidence. …
- Record objective information. …
- Record your assessment. …
- Detail a care plan. …
- Include your interventions. …
- Ask for directions. …
- Be objective. …
- Add details later.
How do you write a nursing assessment summary?
- Your name.
- The date and time.
- Details of any alleged or reportable incidents, including those involving peers or others and, if applicable, any witnesses
How do you note a progress?
- Collect Information. …
- Focused assessment. …
- Analyze the patient’s information. …
- Comment on your sources of information. …
- Decide on the patient issues.