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Structure. The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. Subjective.

Nurses and other healthcare providers use the SOAP note as a documentation method to write out notes in the patient's chart. SOAP stands for subjective, objective, assessment, and plan. Let's take a look at each of the four components so you can understand this neat and organized way of note-taking.

SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record.

The audience of SOAP notes generally consists of other healthcare providers both within the writer's own field as well in related fields but can also include readers such as those associated with insurance companies and litigation.

DAP notes are somewhat less structured than SOAP or BIRP notes and provide a more narrative account of a client's progress in therapy. They're often used in community mental health settings and are helpful for documenting a client's progress in a more holistic way.

Today, it is widely adopted as a communication tool between inter-disciplinary healthcare providers as a way to document a patient's progress.

5 tips for writing strong nursing SOAP notes Don't assume the first complaint is the chief complaint. ... Double check your EMR entries for errors. ... Connect diagnosis with intervention. ... Don't make assumptions about the person reading your notes. ... Limit the Assessment portion of soap nursing notes to appropriate information.