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SOAP CHARTING

By Jocelyn M. Erorita – Dela Vega


BSN, RN
CON - UC
CHART
 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.
CHARTING
 Process of entering information in
the patient’s record.
 Accuracy
 Brevity
 Legibility
Format
 Where and When to Chart
FORMAT
Types

S S S A A S
O O O D P O
A A A P I A
P P P I E P/I
E I I E
E E
R
FORMAT…
Subjective
• Covert
• Symptoms
• Include perceptions, feelings
• Can not be seen
• Stated verbally either by the
patient or the significant other
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.
FORMAT…
Assessment or Nursing Diagnosis
• Clinical judgment

• Basis for selection of nursing


intervention
Types 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 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.
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.


Components of Nsg.
Diagnosis
 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.
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
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…
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…
• 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…
• 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 Charting

Received pt. awake on bed with ongoing


IVF of D5LRS 1L at 800 cc level,
Incorrect charting

infusing well.
 With IFC-UB, draining well
 With O2 inhalation of 2-3 LPM
S  “Haan nak maka-anges” as
verbalized by the patient.
Sample SOAP Charting

Received awake on bed with ongoing IVF of


D5LRS 1L at 800 cc level, regulated at 30
Corrected charting

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”
O  Irritable
 Conscious and coherent
Incorrect charting

 Weak in appearance
 Pale looking
 Vital signs: T = 37.2 BP=120/80
RR = 23 cpm PR= 80 bpm
 Pain at the chest when coughing
Sample SOAP Charting
 Coughs productively at times
O  With audible breath sounds
 With adventitious sounds on upper anterior lobe, both
Corrected charting

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
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.

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