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NAMA:TRI PUTRANTO MAYTAS ARDIYAN

NIM : P07120317072

KELAS: DIV KEPERAWATAN TK 4B

Reading 1

SOAP notes (summary) are that nurses use to record information about a patient. A SOAP
note has four parts- Subjective, Objective, Assesment and Plan.

The subjective is what the patient says about his or her problem. It is the (sypmtoms) the
patient ( or the patient’s family) describes.

The objective is what the nurse sees or obeserves at the time. It is the symptoms that the nurse
can see see,feel, hear, touch and (treat)

The assesment is the nurse (documents) of what the patient’s immediate medical problems
are.

The plan is what the nurse plans to do (help) the patient’s symptoms and (measure) with the
problem

Vocabulary 2

Read Kyle’s SOAP note again and find the expressions or abbreviations in the note which
mean the following

1. meds
2. Pt
3. r/t
4. SOB
5. abdominal exertion
6. Position pt in high fowlers, administer meds via nebulizer
7. RR
8. nebulizer