soap charting

By Jocelyn M. Erorita – Dela VegaBSN, RN

CON - UC

SOAP CHARTING

SOAP CHARTING

CHARTCHART Patient’s record

Legal document

Tool for recording and reporting

Records are written accounts of observations and therapy of the patient.

Reports can be written or verbal accounts.

CHARTINGCHARTING Process of entering information in

the patient’s record.

Accuracy

Brevity

Legibility

Format

Where and When to Chart

FORMATFORMATTypes

SOAPIE

SOAPE

SOAPIER

ADPIE

APIE

SOAP/I

FORMAT…FORMAT…Subjective

• Covert• Symptoms• Include perceptions, feelings• Can not be seen• Stated verbally either by the

patient or the significant other

FORMAT…FORMAT…Objective

• Overt• Signs• Can be seen, observed, heard,

feel• Confirms what the client

verbalizes

Important things to remember…

• Follow the Head-to-Toe process of assessment.

• Pain is a subjective data, the PQRST data should therefore be under the subjective row.

Assessment or Nursing Diagnosis

• Clinical judgment

• Basis for selection of nursing intervention

FORMAT…FORMAT…

Types of Nursing DiagnosesTypes of Nursing Diagnoses Actual – based on the presence of

associated S/S present at the time of assessment

Potential – (risk) clinical judgment that a client is more vulnerable to develop the problem than others with the same condition

Types of Nursing DiagnosesTypes of Nursing Diagnoses Possible – one in which evidence about

a health problem is unclear or the causative factor are unknown.

Wellness – indicates a health response of a client who has achieved/desired a higher level of wellness.

Components of Nsg. DiagnosisComponents of Nsg. Diagnosis

1. Problem Statement Describes the client’s problem or response to

nursing interventions.

Qualifiers: Impaired – used if the status was made worse, weakened, damaged or the functioning

is reduced.

Altered– used if there is a change from baseline, standard, or normal patterns or values.

Ineffective – used if it is not producing the desired effect.

Decrease – reduced in size, amount or degree.

Acute – sudden. Chronic – gradual and long period.

Components of Nsg. DiagnosisComponents of Nsg. Diagnosis

Components of Nsg. DiagnosisComponents of Nsg. Diagnosis

2. Cause Refers to the etiology Explanation of the problem May include behaviors, or environmental factors Utilizes the terms “related to” or “maybe due to” or “due to”

Formulating Nursing DiagnosisFormulating Nursing Diagnosis

One Part Statement

* consist of the NANDA label

e.g. Impaired gas exchange

Fluid volume imbalance

Coping effective

Two Part Statement

* Consist of the problem and the cause (etiology)

e.g. Impaired gas exchange related to accumulation of secretions at the tracheobronchial tubes.

** Fluid volume imbalance related to extracellular fluid shift.

Three Part Statement * Consist of the problem, the cause

(etiology) and defining characteristics.

e.g.1. Impaired gas exchange related to accumulation of secretions at the tracheobronchial tubes as manifested by presence of adventitious sounds on anterior part of both lungs.

e.g. 2 . Fluid volume imbalance related to extracellular fluid shift as manifested by presence of edema on both feet.

Four Part Statement * Consist of the problem, the cause, the

disease (“secondary to”) and the defining characteristics.

e.g. Impaired gas exchange related to accumulation of secretions at the tracheobronchial tubes secondary to pneumonia, as manifested by presence of adventitious sounds on anterior part of both lungs.

Use of “Unknown etiology” * applicable only if the patient’s medical

problem is not yet established or diagnosed.

e.g. Headache related to unknown etiology

Taking into consideration that headache is related to several causes depending on the patient’s case.

FORMAT…FORMAT…Planning / Implementation

Categorized into three interventions

• Diagnostics - interventions/activities that are done to further

seek data or information regarding the patient’s complains (assessment activities)

- include the terms like “monitored”, “assessed”, “checked”, “identified”, “determined”.

FORMAT…FORMAT…• Therapeutic - actual activities done by the caregiver to

“relieve or resolve” the patient’s problem. - Independent actions/interventions

should always come first, followed by those in collaboration with other health team members, and the dependent actions/interventions.

FORMAT…FORMAT…• Educative - health teachings necessary for the

prevention of complications and promotion of health.

- include instructions, explanations, and discussions.

Evaluation Inclusion depends on its necessity.

- However, for specific therapeutic interventions done, evaluation should always be recorded under the “P/I Therapeutic”

E.g. P/I TX:

9:30 body temperature elevated = 38.50 C

TSB done

excess clothings and beddings removed

Paracetamol 1 amp IV given as ordered

10:30 body temp re-checked = 38.00 C

Sample SOAP ChartingSample SOAP Charting

Received pt. awake on bed with ongoing IVF of D5LRS 1L at 800 cc level, infusing well.

With IFC-UB, draining wellWith O2 inhalation of 2-3 LPM

S “Haan nak maka-anges” as verbalized by the patient.

Inco

rrec

t ch

arti

ng

Sample SOAP ChartingSample SOAP Charting

Received awake on bed with ongoing IVF of D5LRS 1L at 800 cc level, regulated at 30 gtts/m, infusing well at the right hand

With O2 inhalation of 2-3 LPM per nasal cannula

With IFC-UB, draining well

S “Haan nak maka-anges”

Co

rrec

ted

ch

arti

ng

IrritableConscious and coherentWeak in appearancePale lookingVital signs: T = 37.2 BP=120/80

RR = 23 cpm PR= 80 bpmPain at the chest when coughing

Inco

rrec

t ch

arti

ng

O

Sample SOAP ChartingSample SOAP Charting Coughs productively at times With audible breath sounds With adventitious sounds on upper anterior lobe, both

lungs (+) use of accessory muscles Pale nailbeds noted Capillary refill = 2-3 secs With cold and clammy skin Needs assistance in performing ADL Vital signs: T = 37.2 BP=120/80 RR = 23 cpm PR= 80 bpm

Co

rrec

ted

ch

arti

ng

O

A = Difficulty of breathing related to accumulation of secretions in the tracheobronchial tree secondary to pneumonia

P/I (Dx) Assessed respiratory and circulatory status Assessed level of dependency/ functioning Monitored V/s and recorded

TX Positioned to fowlers Coached to controlled breathing Backtapping rendered after nebulization

EDX Instructed to do DBE Instructed to increase fluid intake Endorsing with an IVF of D5LRS 1L at 400 cc level,

regulated at 30 gtts/m, infusing at right arm.