It is best if you actually write your SOAP similar to the attachment that I will place here. The rationale is this: on systems that do not pertain, you will not write N/A, Deferred, or leave Blank. Why is that? Recall in your nursing career when you wrote your documentation and then drew a LINE and then placed your name and credentials. This is very similar. If you leave it blank, someone could falsify your documentation. If you write N/A or Deferred and your documentation shows up in court, you might have to justify why you didn’t ask and perform certain items.
Remember:
Keep it simple.
One complaint.
Do not write WNL or Normal (WNL to me means “We Never Looked”: you are novices, describe what the throat looks like)
Your Subjective Data is only what the patient reports…it is not where you place your evaluations
The Objective data is what you observe: not what the patient reports
Any lab values (Rapid Strep Test, Urinalysis, etc) should be placed with the results in the Objective Data because that helps you decide your diagnosis
Assessment: Is Your Diagnosis (Include ICD 10)
You will then provide 3 Differential Diagnoses (diagnoses that it could be if your Primary is not correct) (Include ICD 10)
Your Differential Diagnoses Cannot be your Actual Diagnosis
Plan
Treatment: document exactly what you give the patient
Patient education
Always remind the patient if symptoms persist or worsen to RTC PRN (this will save you legally)
Reflection
What were your thoughts? Would you do things differently?
References in APA format