How to Reference SOAP Notes in APA: A Step-by-Step Guide

When referencing a SOAP note in APA format, the approach will vary slightly based on whether the SOAP note is from a clinical setting, a textbook, or a research study. Below are the key steps to reference SOAP notes correctly in different contexts.

1. Reference SOAP Notes from a Clinical Setting (Personal Communication)

In most clinical settings, SOAP notes are considered personal communications. According to APA guidelines, personal communications are not retrievable by others and are cited differently from published sources. For personal communication, you generally cite the author and date in the text of your document but do not include them in the reference list.

In-text citation example:
(Provider's First Initial., Last Name, personal communication, Month Day, Year)

Example:

  • (J. Smith, personal communication, October 15, 2023)

This citation style is used when referring to a SOAP note or any clinical documentation that is not publicly available (e.g., patient records or notes from a specific clinical encounter).

2. Reference SOAP Notes in a Published Source (Textbook or Journal)

If you are referencing a SOAP note from a published source, such as a textbook, academic article, or clinical guide, you need to follow the APA guidelines for citing books, chapters, or journal articles.

Book citation format:

  • Author’s Last Name, First Initial. (Year). Title of the book: Capitalize first letter of subtitle (Edition, if applicable). Publisher.

Example:

  • Smith, J. (2020). Clinical notes and documentation in nursing practice (2nd ed.). Health Press.

If the SOAP note is part of a chapter in an edited book:

Chapter citation format:

  • Author’s Last Name, First Initial. (Year). Title of chapter. In Editor’s First Initial. Last Name (Ed.), Title of book (pp. page range). Publisher.

Example:

  • Smith, J. (2020). SOAP notes in patient care. In L. Davis (Ed.), Evidence-based nursing practices (pp. 45-60). Medical Press.

Journal article citation format:

  • Author’s Last Name, First Initial. (Year). Title of article. Title of Journal, Volume(Issue), page range. https://doi.org/xxxxx

Example:

In both cases, ensure you follow the correct APA formatting for the source you are citing (book, chapter, or article) and adjust for the number of authors, editors, and other elements.

3. Reference SOAP Notes in Research Studies (Published Research)

If you’re referencing a SOAP note that was part of a research study, you should cite the study as you would for any published research article. These citations typically follow the format for journal articles, as they include a research design, data analysis, and other scholarly components.

Research article citation format:

  • Author’s Last Name, First Initial. (Year). Title of article. Title of Journal, Volume(Issue), page range. https://doi.org/xxxxx

Example:

This citation format is appropriate when SOAP notes are analyzed in a research setting or used as part of a case study to examine clinical practices.

Common Pitfalls to Avoid When Referencing SOAP Notes

  • Don’t Include SOAP Notes from Clinical Practice in the Reference List: SOAP notes in clinical practice are typically considered personal communications. They should only be cited in-text, not in the reference list.

  • Ensure Patient Privacy: Always ensure that no patient-identifying information is included when citing SOAP notes in research or academic papers.

  • Accurate Citation of Published Sources: If you're using SOAP notes from a published book or article, make sure the source is properly referenced, including correct page numbers and accurate publication details.

Conclusion

Properly referencing SOAP notes in APA format is crucial for maintaining academic integrity and contributing to evidence-based practice in nursing and healthcare. Whether you are citing a SOAP note from a clinical setting, a textbook, or a research article, following the APA guidelines ensures that your work adheres to professional and scholarly standards.

Remember to cite personal communications correctly in-text, and if you are referencing published sources, make sure to follow the correct citation format for books, journal articles, or chapters. By mastering these APA formatting rules, you contribute to a clearer, more professional, and credible body of work in nursing and healthcare research.