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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…
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
• 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:
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
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.