"S (subjective data) - chief complaint or other information the patient or family members tell you.

O (objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values. A (assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses. P (plan) - strategy for relieving the patient's problems, including short- and long-term actions. I (interventions) - measures you've taken to achieve expected outcomes. E (evaluation) - analysis of the effectiveness of your interventions. R (revision) - changes from the original care plan" (this information is from page 676 of Portable RN: The All-in-One Nursing Reference, third edition, published by Lippincott, Williams & Wilkins, 2007) These examples of SOAP and SOAPIE charting come from page 677 of the same reference, Portable RN: The All-in-One Nursing Reference, third edition, published by Lippincott, Williams & Wilkins, 2007: "[Nursing diagnosis]#1 Nausea related to anesthetic S: Patient states, "I feel nauseated." O: Patient vomited 100mL of clear fluid at 2255. A: Patient is nauseated. P: Monitor nausea and give antiemetic as necessary. I: Patient given Compazine 1mg IV at 2300. E: Patient states she's no longer nauseated at 2335. [Nursing diagnosis]#2 Risk for infection related to incision sites [notice there is no "S" charted--no subjective data to chart] O: Incision site in front of left ear extending down and around the ear and into neck--approximately 6" in length--without dressing. No swelling or bleeding, bluish discoloration below left ear noted, sutures intact. Jackson-Pratt [JP] drain in left neck below ear with 20mL bloody drainage. Drain remains secured in place with suture. A: No infection at present. P: Monitor incision sites for redness, drainage, and swelling. Monitor JP drain output. Teach patient S&S [signs and symptoms] of infection prior to discharge. Monitor temperature [Nursing Diagnosis]#3 Delayed surgical recovery O: Patient oriented x 3 but groggy. Patient attempted to get OOB [out of bed] at 2245 to ambulate to bathroom but felt dizzy upon standing. Lungs sound clear bilaterally. A: Patient is dizzy when getting OOB. Patient needs post-op education about mobility and coughing and deepbreathing exercises. P: Allowed patient to use bedpan. Assist in getting OOB in 1 hour by dangling legs on side of bed for a few minutes before attempting to stand. Monitor blood pressure. Teach patient how to get out of bed slowly to prevent dizziness and to ask for assistance. Teach coughing and deep breathing, turning, use of antiembolism stockings. I: Allowed patient to lie down in bed after feeling dizzy. Patient used bedpan and voided 200mL clear, yellow urine at 2245. Assisted in coughing and deep-breathing exercises and taught about turning, use of antiembolism stockings. E: Lungs remain clear bilaterally. [Nursing Diagnosis]#4 Acute pain related to surgical incision. S: 2245 patient states, "No" when asked if she has pain. At 2335 patient states, "It hurts." O: Patient reports incisional pain as 7/10 on scale of 0 to 10. A: Patient is in pain and needs pain medication. P: Give pain meds as ordered. I: Patient given morphine 2mg IV at 2335. E: Patient states pain as 1/10."

Terms Definitions ADPIE A= assessment data D= nursing diagnosis P= plan I= implementation of care E= evaluation of care assessment *includes things we observe ask both subjective and objective *head to toe assessment *signs and symptoms the patient has like fevers, V/S, pain *comprehensive and admission assessment data *information the patient or their family tell you *other healthcare worker's documentation about the patient as they are caring for them such as occupational therapy, physicians, physical therapy, RT types of assessment Comprehensive or Admission Data Base: *usually on admission to the hospital or the unit *interviewing: preparatory, introduction, working, termination Focused: *looking at a specific problem like for specific body systems Emergency: *what is happening right now! Nursing Diagnosis1. this is different than the doctor's diagnosis 2. it reflects what have noticed needs attention for your patient 3. it is a NANDA approved diagnosis. We do not make up our own diagnosis! These diagnosis are available in your nursing process book, care plan book etc 4. it is something NURSES can fix without the doctor's order 5. we think about our patient's strengths and weaknesses 6. we do take into account the doctor's diagnosis as well as what treatment orders the doctor has given us in the patient chart. We look at information collaboratively from other health care workers taking care of our patient problem What is unhealthy about patient? etiology What causes the patient to have this unhealthy state? defining characteristics What is the subjective or objective data that tells you there is a problem? plan/goals/outcome*What are you going to do with this patient? *You know all their vital signs, you know what you found out during your head to toe assessment. You know what the doctor and other health care workers say about the patient. You know what treatment orders the doctor ordered. *now ....what does my patient need while I am taking care of them during this shift? Not just what the doctor says, but what I can see based on my nursing diagnosis. Sometimes we plan weeks or montsh in advance *I know what is going on and now i have to decide how i will solve the problem that I can solve without the doctor telling me to do so *I will plan that I can solve it and start listing out the things I can do. I will plan that I can get it done by

a certain time frame. I let others know what my plan is. Cognitive Outcomes tell about the patient's knowledge or intellectual behaviors Psychomotor Outcomes tell us about the patient's achievements in a new skill Affective Outcomes tell us about the patient's values, beliefs, attitudes and any changes Physiological Outcomes tell us about physical changes happening to the patient Outcomes are: 1. written in terms of the patients response 2. are the opposite of the problem 3. relate to only one nursing diagnosis 4. based on problems and not etiologies 5. may have more than one goal 6. are measurable 7. have a target time PLAN interventions consist of things we can: *monitor actions the nurse can take, teaching the patient or family members, referrals to other health care providers *it includes initial planning, ongoing planning and discharge planning *we call these plans: Kardexes, Plan of Care, Care Plans, Care Maps, Clinical Pathways, and Discharge plans 5 rights of delegation 1. right task 2. right circumstances 3. right person 4. right direction/communication 5. right supervision implementation Begin doing what I said I would do. I will state that I am doing it in my plan of care or care plan evaluation 1. did my plan work? 2. did my patient achieve the goals/outcomes? 3. do I need to revise the plans? 4. Should I re-evaluate the patient's assessment? 5. has something changed about my patient? 6. time to reassess 7. or terminate care