NURSING CARE PLAN AND

SOAP NOTES

Compiled By:
Mika Andika, M.Pd.

Nursing Program
A nursing care plan (NCP) is a formal process that includes correctly
identifying existing needs, as well as recognizing potential needs or risks. Care
plans also provide a means of communication among nurses, their patients, and
other healthcare providers to achieve health care outcomes. Without the
nursing care planning process, quality and consistency in patient care would be
lost.
 Purposes of a Nursing Care Plan
 The following are the purposes and importance of writing a nursing care plan:
 Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health and well-being of
clients without having to rely entirely on a physician’s orders or interventions.
 Provides direction for individualized care of the client. It allows the nurse to think critically about each client and
to develop interventions that are directly tailored to the individual.
 Continuity of care. Nurses from different shifts or different floors can use the data to render the same quality and
type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
 Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what
instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is
no evidence the care was provided.
 Serves as guide for assigning a specific staff to a specific client. There are instances when client’s care needs to be
assigned to a staff with particular and precise skills.
 Serves as guide for reimbursement. The medical record is used by the insurance companies to determine what they
will pay in relation to the hospital care received by the client.
 Defines client’s goals. It does not only benefit nurses but also the clients by involving them in their own treatment
and care.
The nursing process includes five key steps:
 Assessment: Collecting and analyzing data to gain a holistic understanding of the patient’s needs and risk factors.
 Diagnosis: Using data, patient feedback, and clinical judgment to form the nursing diagnoses.
 Outcomes/Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis, ideally
with input from the patient. Determining nursing interventions to meet those goals.
 Implementation: Implementing nursing care according to the care plan, based on the patient’s health conditions and
the nursing diagnosis. Documenting care the nurse performs.
 Evaluation: Monitoring (and documenting) the patient’s status and progress towards goals, and modifying the care
plan as needed.
 How to Write a Nursing Care Plan
1. Assess the patient.
The nurse starts by reviewing all relevant data, including (but certainly not limited to): medical history, lab results, vital

signs, head-to-toe assessment data, conversations with the patient and their loved ones, observations from other care
team members, and demographic information. The nurse uses this data to assess the patients: Physical, emotional,
psychosocial, and spiritual needs.

2. Identify and list nursing diagnoses.

After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems)
that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all
nursing diagnoses. The North American Nursing Diagnosis Association (NANDA) curates an official nursing diagnosis
list,
which includes definitions, features, and commonly applied interventions for each diagnosis.
3. Set goals for (and ideally with) the patient.
What are the desired outcomes, and how will the patient get there? The nurse answers these questions based on the
assessment, nursing diagnosis, and feedback from the patient. Together, the nurse and patient set reasonable goals that can
be achieved with nursing interventions and (in some cases) effort by the patient.

4. Implement nursing interventions.

Nursing interventions are actions taken by the nurse to achieve patient goals and get desired outcomes — for example,
giving medications, educating the patient, checking vital signs every couple hours, initiating fall precautions, or assessing
the patient’s pain levels at certain intervals.

5. Evaluate progress and change the care plan as needed.

Finally, the nurse monitors and evaluates the patient and the nursing care plan on a regular basis to answer the question: Are
the nursing interventions helping the patient reach their goals and desired outcomes, and should those interventions be
changed, terminated, or continued?
 SOAP NOTES

A SOAP (subjective, objective, assessment, plan) note is a method of documentation used specifically by healthcare

providers. SOAP notes are used so staff can write down critical information concerning a patient in a clear, organized, and
quick way. SOAP notes, once written, are most commonly found in a patient’s chart or electronic medical records.
SOAP is an acronym for the 4 sections, or headings, that each progress note contains:
 Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include
subjective information from a patient’s guardian or someone else involved in their care.
 Objective: For a more complete overview of a client’s health or mental status, Objective information must also be
recorded. This section records substantive data, such as facts and details from the therapy session.

 Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health
status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation
of all the evidence thus far, and
 Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that
might be made to it.
 Details

Subjective •Subjective data from stakeholders and patients create a

E.g. Patient observations, opinions, experiences
context for the Assessment and Plan sections that follow. 
Example subsections include:Chief or Primary Complaint,
e.g. their condition, symptoms, or historical diagnoses
•History of Present Illness, often further structured into
onset, location, duration, characterization, alleviating and  Patient # Elsie#
aggravating factors, radiation, temporal factors, and severity
(OLDCARTS)
•Patient History, including medical, surgical, family, and
social factors
•Review of Symptoms, which includes pertinent questions
 Subjective Data
about potentially unmentioned symptoms, and
•Allergies and Current Medications. On Tuesday, Elsie presented with 6/10 elbow pain after falling down the stairs 2
weeks prior. She reports implementing her mobility exercises twice each day and that she is
now able to flex her elbow with an 80% range of motion.

Objective
E.g. Test results, Experience Sampling Data
Elsie seems enthusiastic about the exercises and her improvements but has acute
pain when lifting objects over 5lb. She has ceased taking ibuprofen as the pain stopped on
Tuesday.
Wherever any tests or factual data are collected, they should  Objective Data
be recorded along with subjective information for a more
thorough analysis of the client’s condition.
Enhanced weight-bearing capacity and range of motion in her elbow confirm the
strength- and flexibility-building exercise plan is having a good effect

Assessment •An integrated analysis of the combined objective and  Assessment

E.g. Mental health conditions, medical diseases
subjective data to offer a diagnosis. Where an existing
condition is a reason for a mental health program, it will Increase dumbbell exercises to exercise regime to increase elbow strength.
relate to changes in status.Diagnosis/Problem: E.g.
Generalized Anxiety Disorder, Repetitive Strain Injury, etc.
•Differential Diagnosis: If applicable, other potential
diagnoses are noted along with the practitioner’s rationale for  Plan
suggesting them.
Reduce session frequency from 2x week to fortnightly while monitoring
improvement

Plan •A detailed description of any further actions that need to

E.g. CBT, exercise programs, mental health coaching follow from the therapy, e.g.:Further, complementary, or
alternative mental health solutions
•Medication prescribed
•Psychoeducation
•Testing
 THE END

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