Nurses are integral to healthcare, driving essential services and strengthening the health system.

Among their crucial responsibilities, documenting patient information stands out. Patient notes,
detailing assessments before, during, and after treatment, serve as a cornerstone for
compassionate and safe care.

Patient notes serve as a vital record, documenting the assessment of a patient's condition
before, during, and after treatment. This documentation is categorized into three main types:
initial notes capturing the first assessment, interim or progress notes providing ongoing
assessments to monitor the patient's condition, and discharge notes summarizing information
when medication is discontinued or the patient is released from the hospital. These notes,
meticulously compiled by nurses, serve as a crucial repository of information critical for
continuity of care and informed decision-making.

One effective method of organizing patient notes is the SOAP format, which stands for
Subjective, Objective, Assessment, and Plan.

The SOAP format is a structured method used for organizing patient notes, providing a
systematic approach to documenting crucial information.

Subjective:
 Explanation: This section captures the subjective assessment provided by the
patient or their family members. It includes information based on the individual's
feelings, experiences, or observations.

For example: kay kung mag pa check up tau, nurse diba nurse muna mag assists satin and they
questions us kung kailangan nag simula or gaano na katagal or ganaano kasakit or katas ung
lagnat or what and gina take note nila un. Gina take note nila ung

Objective:
 Explanation: In this section, the nurse records objective assessments, which are
observations made by the healthcare professional or findings reflected in
laboratory reports and other medical documents.
 Example: If a nurse observes elevated blood pressure during a routine check-up,
this objective information would be documented in this section.
  For example: after nag the subjective kay eh examine na ung patients like timbangin or
kuhaan dugo or ung temperature, para malaman kung gaano katas ung lagnat or kung
meron problema sa dugo. Un ung objective the Observable, measurable facts.

Assessment:
 Explanation: The assessment section involves the nurse's diagnosis based on the
subjective and objective information gathered. It provides a clinical
understanding of the patient's condition.
Examples: galing sa S and O di inaitial diagnose niya ung patients. Like pataas lagant niya or -
based sa blood pressure niya gi diagnose nong nurse na mag high blood palla niya. Un ung
assessment the Nurse's diagnosis based on S and O.

Ang lastly the Plan

Plan:
 Explanation: This section outlines the plan of action or procedures to be
undertaken to address the diagnosed issues. It lays out the roadmap for the
patient's care.
 Example: The plan for a patient diagnosed with high blood might include
medication, lifestyle changes, and regular monitoring of blood pressure.
Dito na naga bigay advice and medication ung nurse. So ung Plan is Actions to address
the diagnosis.

D lng ang soap ang pwde gamitin meron ding Other patients notes like the PIE format,
DAR format and the APIE format

PIE Format (Problem, Intervention, Evaluation):

 Problem: Describes the patient's problems or nursing diagnoses.
 Intervention: Outlines the nursing interventions or actions taken.
 Evaluation: Assesses the effectiveness of interventions and any changes in the
patient's condition.

1. DAR Format (Data, Action, Response):

 Data: Information about the patient's condition.
 Action: Nursing interventions or actions.
 Response: Patient's response to the interventions.
2. APIE Format (Assessment, Problem, Intervention, Evaluation):
  Assessment: Patient assessment.
 Problem: Identified problems or nursing diagnoses.
 Intervention: Nursing actions taken.
 Evaluation: Assessment of the effectiveness of interventions.

Effective communication is vital in healthcare, impacting relationships, collaboration, and patient

outcomes. Improved nursing communication reduces errors and enhances positive results.
Patient notes, the cornerstone of tracking progress, must be detailed and legible, especially
when staff presence is intermittent. Always employ the SOAP format for clear and standardized
documentation, ensuring a lasting impact on healthcare quality and patient care.