SOAPIER Note Charting Examples

Non-Nursing SOAPIER Note:
(Don't let the words "SOAPIER Notes" or "Issue-Oriented Charting" scare you! The steps of the Nursing Process (reflected in SOAPIER charting) are really something you do every day in multiple scenarios. You are simply going to apply this problem-solving way of thinking and doing to your nursing, and put it in a written form.)

Date/time: 1/10/10, approximately 3pm. Setting: Husband/father returns home, having enjoyed Saturday morning fishing with friends. He walks into the living room and finds his three children«and chaos. #1. Interrupted family processes related to unexplained chaos as evidenced by crying children, cluttered environment, missing caretaker. S: Bobby states, "I'm hungry!" Jennifer and Megan say, "Me, too." Megan reports, "Bobby hit me!" All report, "We don't know where Mommy is." O: All three children are crying. Toys and clothing litter the floor making it difficult to walk. No blood on children or floor. All children are alert and oriented x 3. Wife is not present; does not respond when her name is called. A: The children are hungry. No one is hurt very badly. The living room is a mess. Location of wife/mother not known. P: Find wife. Enlist children to help pick up room. Feed the children. I: Called wife's name in the back yard. Called her cell phone. Found wife on bed where she had accidentally fallen asleep from exhaustion. Told wife to continue her nap ± that I (husband) would take care of things for a while. Helped children pick up toys and clothes. Made peanut butter sandwiches, carrot sticks, and apple "smiles." E: The children stopped crying and cooperated with project "Clean-up." They ate the prepared food, said thank you, and went outside to play in the back yard. After her nap, wife reports feeling much more rested and gave me a kiss. R: Develop a strategy with wife to enable her to get more sleep.

rest. She also had 2 bruises on the top of her right foot which were about 2x2 cm and 1x1 cm in length and width that she reported were from dropping a pan on her foot. She also stated that soaking her feet helps her pain quite a bit. S: MJ states that her feet are still hurting when she walks and cleans the house. She characterizes the pain as burning and aching. She currently puts silver sulfadine on the burns once a day. Continue to treat pain with Tylenol. HR 70.Nursing SOAPIER Note #1: Date: 9/30/09 Setting: Interview took place once again in patients Hogan in Indian Wells. MJ also reports that she has burns between her toes from when she feel asleep next to a fire and didn¶t notice her feet were burning. Acute pain in soles of feet related possibly to disease and medications as evidenced by MJ reporting her feet hurt 10/10. and performing some PT exercises her Dr. and the patient seemed awake and cheerful. 1. MJ¶s feet did not appear swollen. The burns were open with no drainage. but does not cure the pain. Rest seems to be the best way to take away her pain. MJ also reports that she has been ³soaking her feet in warm water every other day and using 2 pills of Tylenol (650mg) for pain´. The interview took place around 9:15 a. or when she remembers. MJ says that this helps. resting after being on her feet.m. The pain is a 10/10. She is concerned because the burns have been there for the past 3 weeks and do not seem to be healing. Her pain could also be from wearing footwear with inadequate arch support. taught her. This includes soaking her feet in warm water. only this time her husband was not present during the whole interview. and heat therapy until MJ¶s doctor appointment on 10/15/09. RR 14. but was wearing flip-flops and didn¶t walk very much.5. O: VS: temp 98. He was in and out of the house doing chores. . MJ was sitting during the interview. Continue to monitor burn healing. The setting was similar to last week. A: MJ¶s foot pain could be due to neuropathy as evident by her reports of ³burning´ and ³aching´ pain. stretches. E: MJ said that Tylenol was helpful but ³didn¶t take away all of the pain´. I: Gave MJ Tylenol for when she runs out next week. which may be healing slowly due to some of her medications (prednisone and previous hydrocortisone use). Performed a focused pain assessment on her feet which got her thinking about non-medicated interventions for her pain. She says the pain usually lasts for about 4 hours at a time and ³often keeps her up at night´. but she did have burns on her left foot between her 3rd and 4th toes. MJ is probably experiencing pain from burns. P: Continue to evaluate her pain each week to see if it gets better or worse. This medication was left over from an injury her husband had previously. They were both about 1x1 cm long and wide and had white edges. She says the pain goes away if she sits and rests for periods at a time.

There may be medication changes after Monday and Tuesday's dr. Home neat and warm. Although her pain rating was at a consent 8/10. S: The client¶s family discussed the concern about their mother/grandmother¶s medication schedule and the fact that she controls all of her medication administration. and side effects. Devise a teaching device (chart) that will simply tell the patient what the medication does. altered mental status. even though her children do not know what the medications do. Granddaughters report pt. how often she can take it. Her vital signs were stable with RR 16 and HR 68. and filled at different facilities. a safe administration plan based on clear knowledge of all medications. Arrived at patient¶s residence. Her doctor appointment is in a few weeks and he will hopefully give her some arch supports or pain medications. and a "bone and joint" appointment on Tuesday of next week. Current medication administration is unsafe and ineffective for pain control. since medications were prescribed by 4 different doctors. Patient's son-in-law answered door and showed me into living room where pt. pt did not know that she was allowed to take her hydrocodone/APAP 1 -2 tablets every 4-6 hours. traditional hair bun was not fixed. Nursing SOAPIER Note #2: Date: 10/7/09 Time: 1310-1420 Visit: Second official visit with my assigned family. She believed that she could only take 1 tablet every 6 hours. Develop. O: When asked about her medication.R: As of now there are no revisions needed. Compare pt medications for any possible interactions. Patient greeted me and seemed to be happy to see me. and family sharing of medications. No adverse medication symptoms noted or reported. . A: Patient and family have a vast knowledge deficit related to prescribed medication. although. wrong time administration. Patient's daughter and two granddaughters were also present. Medication bottles indicate they have been prescribed by 4 different doctors and have been filled at different facilities. Nursing Diagnosis #1: Knowledge deficit related to medication use as evidenced by doubling dosing. when she should take it. She has also been known to share her medications with her children. Roads passable this week. P: Short-term plan: Review all of the information family receives during pt oncology appointment on Monday and the bone and joint appointment on Tuesday. was sitting on couch. They stated that sometimes she would forget that she took a dose of medication and then take another dose. Patient dressed in warm appropriate traditional clothing. appointments. Long-term plan: Continue to assess patient/family medication knowledge. with the family. Good hygiene. has oncology appointment on Monday. pt knew the use of 5 out of the 10 prescribed to her.

I think they really appreciated the idea of me going over the answers or any questions they have regarding their grandmother¶s conditions.I: Engaged in open and respectful communication with daughter regarding her mother¶s medication use. who are the primary caregivers for my patient. Concluded that they are mostly visual learners. medicines. Spoke to family about patient¶s upcoming doctors¶ appointments. R: Will continue with my plans regarding creating a teaching tool as I now know that a visual tool would be the best to facilitate learning. were very happy with the idea of me providing them with questions to ask the doctors. . and treatments. Also. Started slow to figure out which learning model works best. E: The two granddaughters. I will present this teaching tool to my patient and further evaluate the effectiveness of my interventions. Gave them a few questions to ask the doctor concerning her pain. I will research any new medications that my patient is placed on after her doctors¶ appointments. Reviewed a few medications with patient and her family. Next meeting. Also.

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