Nursing Soap Notes Example | SOAP Note Writer

What a Nursing SOAP Notes Entails

A nursing soap note is a documentation written by nurses where they provide information obtained subjectively and objectively in patient assessment. With the information that is derived in soap charting, it is possible to diagnose underlying conditon and even make treatment recomendations.

A nursing soap notes example is provided that makes it possible to obtain insight into how one can write a good soap note. The example clearly identies various sections that make up a nursing soap note and the information that should be included in each section. The example is based on an actual patient case that makes it possible for readers to have clear insight into how they should go about in handling each section.

Descriptive details are also provided which is essential in facilitating learning based on what a nursing SOAP note is and critical writing guidelines. Insight into how one can obtain SOAP note writing services is also provided thus fully meeting needs readers may have.

Our soap note writers have a high level of expertise that will make it possible for learners to obtain insight into how a good soap note entails. Most importanly, the nursing soap note example below will provide all the important guidelines in charting.

SOAP Notes Definition

At first, it is important to understand what a SOAP note entails or to have clear insight into the definition of a SOAP note. The term SOAP usually comprises an acronym that stands for Subjective, Objective, Assessment, and Plan where each section has respective patient health information that should be recorded. The definition for a SOAP note is that it comprises a documentation used in patient assessment to help obtain and record information on underlying symptoms, patient’s medical history, and appropriate treatment recommendations.

According to Wiki How, each of the four sections must be completed with entirety that is critical in diagnosing the underlying condition and even coming up with an effective treatment plan. Each of the four sections will be covered and the information that should be presented in each section clearly illustrated.

Emphasis has made in this article on how to engage in nursing soap charting where an elaborate example is provided along with writing guidelines. With the derived insight, nurses will be in a position to undertake assessments on patients and even come up with effective treatment plans.

Nursing SOAP Charting

Nursing soap charting usually entails the process of writing a SOAP documentation upon the assessment of underlying patient condition. As a nurse, you are going to be required to come up with a SOAP note at some point in your career or learning. It is important for you to understand the guidelines that you should apply as you engage in SOAP charting. The example that we have provided and discussed extensively below clearly illustrates the SOAP note format that should be applied in charting.

Our soap note writer applies the format that is captured in the sample and the format is also standard for all documentation. Therefore, if you are experiencing difficulties in undertaking your assessment, you can understand how you can come up with subjective, objective, assessment, and plan sections. The nursing soap charting example below will place you at a better position for writing a perfect documentation.

Nursing SOAP Notes Example

The following is a nursing soap note example where the information that should be included in each section has been discussed and identified. This example is based on an actual patient case that makes it possible for readers to have clear insight into how they should go about in handling each section.

By considering the information provided in this example of a nursing soap note, it will be possible to come up with a soap note that meets required thresholds. This example has been prepared by our best soap note writer and it should not be copied for personal use.

Week 6 SOAP Note Assessment: Family Assessment and Psychotherapeutic Approaches

Comprehensive SOAP Note: Mother and Daughter-A Cultural Tale

Subjective:

CC: Family conflict

History of Present Illness (HPI): The patient in as immigrant who presents for a medical interview accompanied by her daughter aged 23 years and her therapist. She immigrated into the United States 12 years ago with her four children from Iran through a medical visa. One of her daughters that has accompanied her for the interview and who was aged 8 years at the time was left behind with her father in Iran. However, the father abused her emotionally, physically, and sexually before she later moved into the US to live with her mother 2 years ago. The mother has completely separated from her husband but has a history of domestic abuse from the marriage. Currently, the mother is disabled following a failed leg surgery that has rendered her inactive and made it impossible for her to work or even to operate independently. The main reason why the mother and daughter went for therapy is as a result of family issues or conflict. The mother claims that her daughter has not been there for her to provide support and help. She currently explains that she had been depressed and that this daughter, rarely spends time with her despite not having a full-time job. On the other hand, the daughter indicates that she has a lot to do and that the mother has to learn living independently.

Past Psychiatric History:

• General Statement: The mother explains that she is depressed following her current state where she is disabled that has made it impossible for her to operate independently.
• Caregivers: The mother currently lives with two of her children who assist in providing care to her. Her married daughter and spouse also provide support to her that has helped sustain her.
• Hospitalizations: The mother was previously hospitalized where she underwent two surgeries that failed and rendered her disabled.
• Medication trials: No history of medical trials.
• Psychotherapy or Previous Psychiatric Diagnosis: No present/past diagnosis of any psychiatric condition. However, patient acknowledges that she is currently depressed following her current state.

Substance Current Use and History: No current or history of substance use.

Family Psychiatric/Substance Use History: Father has a history of smoking and alcohol abuse. However, the daughter has a history of emotional history following physical and emotional abuse from her father and current experienced with her mother (See appendix 1). Father was emotionally unstable and violent causing her to abuse his wife and children.

Psychosocial History: The mother is currently disabled and spends most of her time at home watching TV and performing simple chores such as cooking. She currently lives with two of her children and two pet dogs. She frequently visits her elder daughter who is married. She rarely interacts with other individual in her community or even engaging in social activities such as going out with friends. On the other hand, the daughter currently lives on her own but visits her mother for a few hours in a week. She has no full-time job but is busy running errands to earn a living. She enjoys spending time with her friends especially during the weekends. She denies engaging in risky activities such as drug use.

Medical History:

• Current Medications: No current medications
• Allergies: No known allergies
• Reproductive Hx: Regular menses for both individuals

Review of Symptoms (ROS):

• GENERAL: Signs of weakness for the daughter. Mother appears stressed.
• HEENT: No headache for both patients. Normal eyesight for the daughter. Mother has short-sightedness. Normal hearing ability. No runny nose and a sore throat.
• SKIN: No any form of rash or itching for both patients.
• CARDIOVASCULAR: No chest tightness experienced or chest discomfort, as well as a racing heart in episodes of fifteen minutes.
• RESPIRATORY: Normal breathing is exhibited for both patients.
• GASTROINTESTINAL: No stomach complications such as vomiting, abdominal pain, and constipation among others are reported for both patients.
• NEUROLOGICAL: No dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
• MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
• HEMATOLOGIC: No anemia, bleeding, or bruising.
• LYMPHATICS: No enlarged nodes.
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance.

Objective:

Physical exam:

• Vital signs (mother): T- 98.9 P- 94 R 20 125/89 Ht 5’6 Wt 180 lbs
• Vital signs (daughter): T- 97.8 P- 92 R 18 123/78 Ht 6’2 Wt 116 lbs
• GENERAL: The glooming and hygiene for both the mother and daughter are remarkable. The mother appears overweight while the daughter looks weak and emaciated. Both patients appear tired and unhappy at the onset of the interview but their mood changes towards the end of the interview.
• HEENT: No tumors, masses or abnormal swellings were identified on his head. Proper vision exhibited for the daughter. Mother is short-sighted but has glasses.
• NECK: No glandular or the enlargement of the thyroid was identified. No masses.
• RESPIRATORY: Normal breathing was exhibited at the moment. No abnormal sounds that could be a sign of obstruction in the airways were identified.
• CARDIOVASCULAR: Normal pulse rate for both the mother and daughter.
• GASTROINTESTINAL: Normal bowel sounds and movements.
• MUSCULOSKELETAL: No swellings, redness, and even pain was exhibited in the joints, muscles, and the bones. Mother unable to walk independently following a failed surgery.
• NEUROLOGICAL: proper motor function and coordination exhibited.

Diagnostic results:

• Psychological Evaluation: Given the behavior and the nature of the relationship between the mother and the daughter, there is a need for conducting a psychological evaluation for both patients. The two should be closely examined by a psychologist or a psychiatrist to help determine if they are experiencing any mental health problems such as stress or depression (Vane & Motta, 2017). Additionally, this will also help determine the nature and extent of each individual’s medical illness.

Assessment:

Mental Status Examination: It is clear that both the mother and the daughter have unstable mental states that could be contributing to the underlying conflict. At first, the mother is stressed and depressed given the inability to function normally. On the other hand, there is a high likelihood that the daughter is highly stressed following the pressure that her mother is putting on her along with the effects of abuse in her childhood.

Differential Diagnoses:

• Depression: This condition is associated with feeling sad, down or upset. Individuals that experience this condition usually have signs such as decreased energy, difficulty in making decisions, persistent feeling of sadness, anger, irritability, restlessness, and hopelessness among others (Holland, 2018). Given the state and symptoms expressed in the mother, there is a high likelihood that she has depression.
• Psychosis: This condition is associated with an impaired relationship with reality. Individuals that have this condition usually exhibits symptoms such as difficulty in concentration, depression, withdrawal from family and friends, anxiety, and suspiciousness among others (Marcus, 2015). Given the symptoms that have been captured in the mother, she could also be suffering from this condition.
• Psychotic depression: This is a condition that occurs when the symptoms of depression are accompanied with those of psychosis. People that have this condition usually get angry for no apparent reason. Other symptoms that are exhibited include intellectual impairment, intense feelings of impairment, and lack of touch with reality (Swartz and Shorter, 2016). Given the symptoms expressed in the mother, there is a likelihood that she could also be suffering from this condition.
• Stress and anxiety: People usually report feelings associated with stress when demands are placed upon them. Feelings of stress are also triggered by events that usually make an individual frustrated and nervous (Legg, 2020). On the other hand, anxiety is associated with feelings of worry and unease Given the experience that both the mother and the daughter have had, there is a high likelihood that they could be both be suffering from stress and anxiety.

Primary diagnosis: Mother: psychotic depression Daughter: Stress

Reflection:

Given the video presented, it is clear that the interviewer has facilitated the engagement between the mother, daughter, and the therapist in an excellent way. At first, the therapist has been used as an intermediary that has helped reveal details about the family given her time working with the mother. This has also helped to make the mother and daughter confident in sharing due to their trust to the therapist. Appropriate questions have been applied for the interview that have revealed details about what could be causing conflict between the mother and the daughter. Each individual is given appropriate time to present their argument without victimization. In such an encounter, I would employ a similar strategy where I would engage or involve the therapists that have dealt with members of the family to help establish trust.

Case Formulation and Treatment Plan:

Case Formulation:

Presenting complaint: Both the mother and daughter have presented for therapy following underlying differences that have made it almost for them to co-exist in peace.

Case presentation: Currently, the mother is disabled following a failed leg surgery that has rendered her inactive and made it impossible for her to work or even to operate independently. The main reason why the mother and daughter went for therapy is as a result of family issues or conflict. The mother claims that her daughter has not been there for her to provide support and help. She currently explains that she had been depressed and that this daughter, rarely spends time with her despite not having a full-time job. On the other hand, the daughter indicates that she has a lot to do and that the mother has to learn living independently.

Psychiatric symptom and diagnosis: It is clear that both the mother and the daughter have unstable mental states that could be contributing to the underlying conflict. At first, the mother is stressed and depressed given the inability to function normally. There is a high likelihood that the mother could be suffering from psychotic depression given that she confesses that she has depression and due to the constant pressure that she places on her daughter. She fails to acknowledge that her daughter is an adult buts puts pressure on her to visit her. She insists that things should go her way and fails to emphasize with her daughter who raises her concerns. The mother seems to have lost touch with the reality and given that she has depression, she is more likely to be suffering from psychotic depression. On the other hand, due to the pressure that the mother places on her daughter, she is more likely to be suffering from stress. This also explains why she seems to be avoiding her mother given that she presents as stressor.

Treatment Plan:

• The most appropriate intervention for the presented case is therapy. Given that therapy has already been initiated, there is a need for continued intervention for the mother, daughter, and other members of the family. The following forms of therapy would be effective:
• Interpersonal therapy: Interpersonal therapy should be undertaken for both the mother and the daughter. Each individual should undertake 10 to 20 sessions where they will be taught how to communicate and express oneself. In the process, each individual should be taught to understand nature of their state and need for emphasizing with one another.
• Cognitive behavioral therapy (CBT): The mother has to be taken through CBT where the main motive will be to teach her to adjust her thoughts to be more rational as where as her behavior and her action. In the process, the mother should be made to understand that her state will not change and that she should learn to live independently without having to put pressure on others including her own children.

References:

• Holland, K. (2018). Depression and anxiety: Symptoms, self-help test, treatment, and. Healthline.
• Legg, T. (2020). Stress and anxiety: Causes and management. Healthline.
• Marcus, E. (2015). Psychosis: Psychological, social and integrative approaches. Psychosis, 4(3), ebi-ebi.
• Swartz, C. M., & Shorter, E. (2016). Diagnosis in psychotic depression. Psychotic Depression, 59-127.
• Vane, J. R., & Motta, R. W. (2017). Basic issues in psychological evaluation. Psychological Evaluation of the Developmentally and Physically Disabled, 19-39.

Detailed Description based on Each Section of a Nursing SOAP Note

Having provided a detailed example of a nursing soap note, we are going to discuss information on the details that should be included in each section. This will make the feedback provided clearer and also offer insight into how to write a good soap note.

Introduction Section of a Nursing SOAP Note

This section of the SOAP note usually requires an individual to provide information regarding the conditions that may be underlying in the patient. For instance, a patient may be presenting for a mental health assessment where brief information regarding mental health assessment can be discussed. One can also provide general information regarding a patient’s health.

Part 1: Subjective Section of a Nursing SOAP Note

This is the first section of a nursing SOAP note where one has to provide information regarding the patient health and social history. The information that is obtained in this section is very important since it makes it possible to understand the condition that is underlying in the patient. At first, one must begin by identifying the chief complaint which is the main issue that is presented in the patient as seen in the soap note example above.

The information that is featured in the subjective section of a nursing SOAP notes usually comprises the information that a patient shares regarding their health. As illustrated in the nursing soap notes example, one should provide details about history of present ilnesses (HPI) after identifying the chief complain. This should be followed by information about the past pyschiatric history, family history, and substance use history. These details can be very signficant in the diagnosis of underlying conditions and should not be left out.

Part 2: Objective Section of a Nursing SOAP Note

While coming up with a nursing SOAP notes, one usually provides their own perception regarding the symptoms that are presented in the patient. Generally, one usually provides information based on the question they ask the patient and even what they observe. The objective section should comprise information that the healthcare professional identifies as they assess a patient. Details about vital signs should be provided where information on signs such as temperature and blood pressure are provided.

As exhibited in the nursing soap notes example above, one should begin by providing information obtained through physical assessment. Details that are similar to those provided in the objective section are provided but the information is based on what a healthcare professionals identified. For instance, one must provide information about the review of symptoms (ROS) which is also provided in the subjective part.

Part 3: Assessment Section of a Nursing SOAP Note

This section of a nursing SOAP note requires you to provide details regarding various conditions that have to be considered for differential diagnosis. Various conditions that are considered for diagnosis are listed and a primary diagnosis selected. With the information obtained upon assessment, it can be possible for a competent healthcare professional to decide on the conditions that a patient is likely to be suffering from.

Various probable underlying conditions should be included in the assessment section of a nursing soap note in the order the conditions are likely to be affecting the patient. With this insight, one should the select the condition that has a high likelihood of affecting the patient. The nursing soap notes example we have provided clearly shows how the conditions should be identified and even how a primary diagnosis should be illustrated.

Part 4: Plan Section of a Nursing SOAP Note

This section is important since it provides guidelines based on the activities that have to be undertaken to promote recovery in the patient. To effectively come up with this part, one must ensure that they diagnose the underlying condition with clarity. The plan section of a nursing SOAP note usually identifies various directives that should be undertaken in treatment. The medications that are best suited to addressing the underlying condition should be identified in this part.

Other details that should be included in the plan section comprise information on follow-up and patient management practices. It is important to include details about when a patient should return for follow-up and even the practices that they should take to promote recovery. These directives are very critical in enabling the patients and home-based care givers undertake approriate care practices. Additionally, a good SOAP note should also have a reflection section and a conclusion section.

Reflection Part

The reflection is very important for one’s professional growth and even for the wellbeing of the patient. While coming up with a reflection, one should ensure that they provide their thoughts regarding the lessons learned and even what they may have observed or even thoughts elicited. While writing the reflection section of a nursing SOAP note, one also has to capture information regarding how the lesson learned can influence their future practice. It can also be crucial to provide details about the new ideas that came up based on activities undertaken in assessment. You can obtain guidance from the best soap note writer that will enable you write a good reflection in case you are experiencing any difficulties.

Conclusion of a Nursing SOAP Notes

This section helps to bring closure to the nursing SOAP notes where one provides a summary of the main issues that came up and the actions that were taken. When writing a conclusion, you can briefly identify the condition diagnosed and even the proposed treatment guidelines. Additionally, it is important to include a list of sources that were used in providing the information discussed. You can chat with a SOAP note writer that will enable you come up with a good conclusion thus meeting all important requirements for your documentation.

SOAP Notes Writing Services

If you are struggling with writing your nursing SOAP notes you can obtain soap note writing services that will enable you come up with a good documentation. We have the best soap note writers and therefore, do not hesitate to reach out to us for any writing support. The soap note example that is provide offers proof that our experts have clear insight into how to come up with a good documentation.

Therefore, if you need nursing soap notes essay help, you can simply place an order for your essay. Simply follow the ordering process and provide us with details on your essay. Alternatively, you start a chat with us where we can guide you on how go about in placing your order. You can apply the nursing soap notes example provided in conducting assessments or seek help from our soap note writers.