SOAP and FDAR Charting

Assessment
1. Initial Assessment – performed after the patient was been admitted
Purpose: for baseline data

2. Problem-Focus Assessment – performed ongoing process integrated into nursing care

Purpose: determine the current status of the initial or previous identified problems

3. Emergency Assessment – looking for the physiologic and psychologic crisis of patient

Purpose: To identify the life-threatening condition of the patient

4. Time-lapsed Re-assessment -few days or months; etc. after initial assessment

Purpose: determine the health status and compare it to your initial assessment

 4 STEPS:
A. Collect Data
 Subjective/Covert data/Symptom – verbalized by the patient
 Objective/Overt data/ Sign – products the senses of the nurse
 2 Sources of Data
a. Primary Source Data – Patient
b. Secondary Source Data – Other than the patient; the patient previous records
 2 Methods of Data Collection
a. Observation – uses of senses
b. Interview – face to face conversation with a purpose
 Directive – structure interview; prepare question
 Non-directive - someone will directly interview; no prepared question;
patient controls the interview
B. Organizing the Data
- Using a different system
C. Validate the Data
- How? Confirm or double-check with the patient
D. Document the Data
 Diagnosing
- Incorporate responses to actual and potential health problems and life process
- Basis for interventions
 Types:
A. Actual Diagnosis
- The health problem is actually present during the time of assessment

B. Potential/High-risk Diagnosis
- Potential: there is no obvious problem at the time of assessment, however, the
patient is vulnerable to acquire

C. Possible Diagnosis
- The evidence about a problem is unclear

D. Wellness Diagnosis
- The healthy response of the patient
- Denoted “readiness”

 Different Components of Nursing Diagnosis

A. Problem Statement/ Diagnostic Label
- Describes client health status (altered, impaired, decreased, ineffective)
- Nursing diagnosis (specific)
B. Etiology
- Caused of health problems (related to)
C. Defining Characteristics
- Consist of data collected
- Indicate presence of health problems

*Formulation and Variations

Planning
1. Setting Priorities
- Establish order for nursing interventions/ strategies
- Guide:
a. Patient’s verbalization
b. Maslow’s hierarchy of needs
c. CAB (Circulation Airway Breathing)

2. Establishing Goal: expected outcomes

a. Goals – long term and broader objective (more than 72hrs)
b. Objectives – lesser than 72hrs; SMART criteria
Sustainable; Measurable; Attainable; Realistic; Timely
 *heat dissipates when there is an increase in blood circulation

Example: After 72hrs of independent nursing and dependent nursing interventions the patient’s care
temperature will have stable body temperature.

3. Selecting Nursing Interventions/ Strategies: the resolution of the problem

 Criteria:
a. Safe and appropriate for an individual: age; gender; educational attainment
b. Achievable with available resources
c. Nursing interventions must be congruent with the client’s beliefs and practices
d. Congruent with other therapies
e. Based on nursing knowledge
f. Must be within established standards of care

 Categories:
A. Diagnostic: interventions for continuous assessment
B. Therapeutic: interventions that directly resolution to the problem
*Independent Interventions: without a doctor’s order (you can do)
*Dependent Interventions: prescribed by the doctor
C. Educational: health teaching rendered to a patient

4. Developing a Nursing Care Plan: written guide that organizes information about the client’s
care

 Importance:
a. Provides direction for individual care
b. Provides continuity of care
c. Provides complete documentation
d. Serves as guide for assigning staff

Implementation
 Skills:
a. Cognitive Skills
b. Interpersonal Skills
c. Technical Skills
 Evaluation:
- Client’s progress
- Effectiveness of nursing intervention