Conceptual Framework Ensuring that level II nursing students competency in SOAPIE charting shows sufficient practical experience to develop

the full range of skills they need for effective practice has become a focus in conducting this study. The hospital related learning experience is an

important learning factoring in doing the SOAPIE charting. In the research paradigm, the study focuses on doing the charting in the level II nursing students, If the have meet the competency by the opportunity to utilize the theory and skills they have learned in the classroom discussion and skills laboratory and imply it in doing the SOAPIE charting and it will perceived by their clinical instructor. The related learning experience (RLE) duties in the hospital will serve as a tool to enhance more the

knowledge, develop the skills, and improve in formulating SOAPIE charting skills of the nursing students.

Definition of terms:

SOAPIE charting -is based on a problem or nursing diagnosis list. Each diagnosis has its own number that never changes. When a SOAP entry is made, it is preceded by the problem or diagnosis number and/or name to which it refers. Following diagnosis identification, information related to the diagnosis is charted in the following manner: S (subjective). Anything the patient says; also may include statements made by family members. O (objective). Observed data; avoid stating opinions: “Just the facts.” A (analysis) (also known as “assessment”). This is the recorder’s chance to state what he or she “thinks” about what he or she has seen and heard. This is usually done in the form of a diagnosis (nurses use nursing diagnoses). P (planning). Includes nursing actions implemented or to be implemented. Therapy, teaching, and plans for further assessment are included regarding the diagnosis in A (analysis). The plan states who will implement and when implementation is to take place. (It is important to remember that the reason many things don’t go “according to plan” is that there never was a specific plan.) I (intervention). Documents implementation if not covered in

Plan. E (evaluation). Documents the effects of the Plan (and intervention if category is used) on the Analysis (diagnosis). It may be entered at a different time from the initial SOAP entry. Competency -Physical, mental, financial, or legal power to perform: ability, capability, capacity, competence, faculty, might

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