soap charting
TRANSCRIPT
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
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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
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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.