SOAP vs SBAR - Documentation Made Simple

Your notes won’t protect you just because you wrote them.

Most nurses use SOAP and or SBAR.

Very few apply them correctly.

That’s where the risk starts.

❌ Vague terms like “patient stable”

❌ Subjective and objective all mixed up

❌ Long, messy blur in one section

❌ No clear recommendation in SBAR

When a note gets challenged…

It’s not how much you wrote.

It’s how clear and structured it is.

Here’s the cheat:

🟢 SOAP = your written record

• Subjective: What the patient says

• Objective: What you observe

• Assessment: Your judgment

• Plan: What happens next

🟢 SBAR = your voice

• Situation

• Background

• Assessment

• Recommendation