Best Practices for SOAP Notes in Nursing

Subjective, Objective, Assessment, and Plan. As a medical professional, you understand the importance of SOAP notes. This notetaking method is an easy way to document patient information in a digestible way so that everyone can provide the best care for their patients. Familiarizing yourself with the best practices for SOAP notes in nursing can’t hurt, whether you’re new to the field or need a refresher. You can enhance your facility’s efficiency by knowing these best practices, either way.

Always Double Check for Errors

As a medical professional, you’re juggling a million responsibilities at once. However, every patient deserves equal care and attention. Finding the appropriate time to write your notes is key to reducing the number of errors you may find after reviewing them. Always double-check your work before submitting it to the database. These notes will help other professionals treat patients and measure their healing journey.

Keep Your Notes Clear and Concise

Wording plays a major role in your documentation. A great practice to remember for SOAP notes in nursing is to keep your language clear and concise. For example, if you prompt your patient to write their name, and they clearly show difficulties, your notes should state: “Provided with paper, pen, and verbal instructions, the patient was unable to write their name legibly.” The statement is accurate but concise and clear.

Avoid Overly Zealous Language

Keeping your language simple is crucial when writing your SOAP nursing notes. Adding overly positive or negative phrasing without evidence can affect your patient’s treatment. Instead of saying, “Patient couldn’t remember his address,” you should say, “Patient could not verbalize their address after being prompted by a nurse.” The latter statement is less judgmental and gives more specific information for other medical professionals.

A nursing clipboard is necessary to ensure your notes remain confidential, professional, legible, and secure. Carstens understands that a clipboard is an essential tool for many medical facilities. Therefore, we created high-quality tools to instill a dynamic, efficient environment that can endure rigorous use. We have the supplies you need to ensure longevity and durability, from foldable nursing clipboards to emergency department covers.