How can I write better SOAP notes?

Question

I'm not too great at writing them and I feel like I need to get my act together before (God-forbid) one day they're subpoenaed and then I'm screwed.

Despite the amount of practice that was given in school, I still feel unconfident and incompetent (about writing them). Any advice?

Answer 1

In simple form SOAP notes can be boiled down to:

Subjective: what the patient tells you

Objective: what your physical examination and any diagnostic testing reveals.

Assesment:  Your diagnosis based on the S&O

Plan: what you intend to do to remedy, relieve or treat the diagnosis.

When writing the subjective, when possible place exact statements in quotes.

When writing the objective, try to use appropriate terminology which would be universally understood by any health care provider reading the notes.  ie malodorous and purlulent is better terminology than the oft used smelly p***y drainage, which I have often seen. Incidentally p***y is a cat and not a type of drainage.

When writing your assesment use diagnoses which are within your scope of practice.  An RN should not put down Rheumatoid Arthritis as it is a medical diagnosis, they should restrict themselves to nursing diagnoses.

When writing your plan have defined measures and goals.

Hope this helps