Creating thorough nursing SOAP notes requires following the proper format and utilizing pertinent information related to the patient's condition. One of the things I used to struggle with when preparing SOAP notes was that my love of writing often made my notes look more like long narrative notes instead of formulated SOAP nursing notes. When writing these notes, keeping content specific and relevant to the patient's current complaint or condition is essential. There are a few elements that should be excluded from nursing SOAP notes, including the following.

1. Information that Is Irrelevant to the Patient’s Current Condition:

The SOAP nursing note should address issues the patient is currently experiencing. Irrelevant information or information unrelated to the current complaints, symptoms, or treatment plan should be avoided.

2. Speculations About the Patient’s Symptoms or Feelings:

Your job when writing SOAP nursing notes is to document the facts as they are presented by the patient, caregiver, or objective data. Speculating about what a patient is thinking or feeling should be avoided. Instead, pay attention to what your patient says and how he acts, and document what you see and hear.

3. Confusing Pronouns:

When documenting in a SOAP nursing note, be careful to use appropriate titles and names instead of confusing pronouns. For instance, instead of writing, "She instructed the client to state her name," you should write, "Clinician asked the client to state her full name, and pt was able to do so."

4. Avoid Judgmental Statements:

As you interview patients and caregivers, there may be times when the source of information tells you something that you feel is inaccurate or inappropriate. It is your job to document findings accurately and nonjudgmentally, even if you feel sure the information they provide is incorrect. For example, if you have a pediatric patient whose mother states the child began walking at five months of age, instead of writing, “The pt’s mother is obviously mistaken because she says he started walking at five months of age," you should write, "Pt.'s mother reports pt. took first steps at approximately five months of age.”

5. Avoid Using Slang Terms or Unprofessional Phrases:

When writing SOAP nursing notes, your statements should reflect a professional voice and avoid slang terms or phrases. Imagine caring for a patient who is beginning to ambulate with assistance after surgery. Instead of writing, “Pt. walked in hallway and had an awesome time,” it is more appropriate to write, "Pt. ambulatory in the hall with minimal assistance; displayed a cheerful effect and tolerated the walk well."