Nursing

Documentation
SOAP
NOTE

Dien’s
  The SOAP note is a method of
documentation done by health care
providers to write out notes in a
D patient's chart, along with other
E common formats, such as the
F admission note.
I  The four components of a SOAP note are:
N – Subjective
I
T – Objective
I – Assessment
O – Plan
N
SOAP NOTE

 A medical SOAP note is a method of charting

information, appointments and progress with a patient.

 The notes are kept in the patient's chart for future

reference and to track overall progress.
 The SOAP note includes the subjective (what the
patient is presenting with), objective (what the medical
professional observes), assessment (diagnosis or
declaration of facts presented) and the plan (plan of
treatment for the presenting issue).
 To properly write a SOAP note, you must learn the
parts of the note and how to use them to chart patient
progress.
SOAPIER METHOD
The seven components of SOAPIER note are:
 Subjective
 Objective
 Assessment
 Plan
 Implementation
 Evaluation
 Revision = Changes of midwifery care
 VOCABULARY
 Health Care Provider (n)
 Document (v)
 Documentation (n)
 NURSING CARE PLAN
(NCP)
 ASSESSMENT (n)
 DIAGNOSIS (n)
 PLANNING (n)
 INTERVENTION (n)
 EVALUATION (n)
 Petugas kesehatan
 Mendokumentasikan
 Dokumentasi
 Rencana asuhan
keperawatan (askep)
 Pengkajian
 Diagnosis
 Perencanaan
 Intervensi/tindakan kep.
 Evaluasi
 Subjective component
 This describes the patient's current
condition in narrative form.
 The history or state of experienced
symptoms are recorded in the patient's
own words.
 It will include all pertinent (related) and
negative symptoms under review of body
systems.
 Pertinent Medical history, surgical history,
family history, social history along with
current medications and allergies are also
recorded.
 Objective component
The objective component includes:
 Vital signs

 Findings from physical examinations, such

as posture, bruising, and abnormalities

 Results from laboratory

 Measurements, such as age and weight of

the patient.
 Assessment
 Is a quick summary of the patient with
main symptoms/diagnosis including a
differential diagnosis, a list of other
possible diagnoses usually in order of
most likely to least likely.
 When used in a Problem Oriented Medical
Record, relevant problem numbers or
headings are included as subheadings in
the assessment.
 Plan
 This is what the health care provider will
do to treat the patient's concerns.
 This should address each item of the
differential diagnosis.
 A note of what was discussed or advised
with the patient as well as timings for
further review or follow-up may also be
included.
 Often the Assessment and Plan sections
are grouped together.
 Description of PLAN
 Note that the plan itself includes various
components:
 Diagnostic component - continue to

monitor labs
 Therapeutic component - advance

diet
 Patient education component - that is

progressing well
 Disposition component - discharge to

home in the morning

 An example of SOAP Note
Surgery Service,
Dr. Jones

S No Chest Pain or Shortness of Breath. "Feeling

better today." Patient reports flatus
O Afebrile, P 84, R 16, BP 130/82. No acute
distress.Neck no JVD, Lungs clearCor RRRAbd
Bowel sounds present, mild RLQ tenderness,
less than yesterday. Wounds look clean.Ext
without edema
A Patient is a 37 year old man on post-operative
day 2 for laparoscopic appendectomy, recently
passed flatus.
P Recovering well. Advance diet. Continue to
monitor labs. Prepare for discharge home
tomorrow morning.
 An example of SOAP Note
DATE TIME ASSESSMENT SOAP
20/7/12 09.15 Wound infection resulted S = Pt complains of
from Cesarean Section having pain around
the wound, burn
when palpated
O = Greenish color
on the wound
dressing, pus exists

A = The wound has

infection
P = Do wound care
Jane Staunton

Signature
 An example of SOAPIER Note
DATE TIME ASSESSMENT SOAP
20/7/12 09.15 Wound infection resulted S = Pt complains of
from Cesarean Section having pain around the
wound, burn when
palpated
O = Greenish color on
wound dressing, pus
exists
A = Wound has infection

P = Do wound care

I = Wet wound with

NaCl 0.9% as instructed

E = Wound still has pus

R = Change dressing
twice a day
 Widhayanti putri, 31
DATE TIME ASSESSMENT SOAP
20/7/12 1.40 hyperemesis S = Pt complains of
having headache felling
dizzy and vomit
O = P : 84, r : 18, BP:
120/90, without
oedema, fatigue
A = pt with hyperemesis
and dehydration
P = bed rest and
rehydration with
electrolytes by infusion
I =give pt glucose
electrolytes and vitamin

E =pt look weary and

weak
 Widhayanti putri, 31
DATE TIME ASSESSMENT SOAP
20/7/12 1.40 Wound infection resulted S = Pt complains of
from episiotomy having blood around the
wound after episiotomy
O = BP: 1OO/70, having
wound, fatigue

A = bleeding and
infection
P = bed rest and
rehydration with
electrolytes by infusion
I = wet wound with
Na.cl 0,9 %, do wound
care, do stitching and
give glucose electrolyte

E =pt look anxious and

Nursing Care Plan (NCP)
Definition of NCP
 A nursing care plan outlines the
nursing care to be provided to an
individual/family/community.
 It is a set of actions the nurse will
implement to resolve/support nursing
diagnoses identified by nursing
assessment.
 The creation of the plan is an
intermediate stage of the nursing
process. It guides in the ongoing
provision of nursing care and assists
in the evaluation of that care.
Characteristics of the nursing care plan
 Its focus is holistic, and is based on the clinical
judgment of the nurse, using assessment data
collected from a nursing framework.
 It is based upon identifiable nursing diagnoses
(actual, risk or health promotion) - clinical
judgments about individual, family, or
community experiences/responses to actual or
potential health problems/life processes.
 It focuses on client-specific nursing outcomes
that are realistic for the care recipient
 It includes nursing interventions which are
focused on the etiologic or risk factors of the
identified nursing diagnoses.
 It is a product of a deliberate systematic process.
 It relates to the future.
 Nursing Process
Care plans are formed using the nursing process:

1. ASSESSMENT
2. DIAGNOSIS
3. PLANNING
4. INTERVENTION
5. EVALUATION
1. ASSESSMENT

 First, the nurse collects subjective data

(complaints) and objective data (results of
observation including lab test results), then
organizes the data into a systematic
pattern.
 This step helps identify the areas in which
the client needs nursing care.
 Based on these data, the nurse makes a
nursing diagnosis
1
2. DIAGNOSIS
• As mentioned above, the full nursing
diagnosis includes the relating factors and
the evidence that supports the diagnosis.
• For example, a nurse may give the following
diagnosis to a patient with pneumonia that
has difficulty breathing: Ineffective Airway
Clearance related to tracheobronchial
infection (pneumonia) and excessive thick
secretions as evidenced by abnormal breath
sounds; crackles, wheezes; change in rate
and depth of respiration; and effective cough
with sputum.
• (This Nursing Diagnosis is taken from the list of NANDA's functional
health patterns,Disturbed pattern is "Activity and Exercise pattern")
2
3. PLANNING
 After determining the nursing diagnosis by using
the PES system (Problem, Etiology, Signs and
Symptoms), the nurse must state the expected
outcomes (goals).
 A common method of formulating the expected
outcomes is to reverse the nursing diagnosis,
stating what evidence should be present in the
absence of the problem.
 The expected outcomes must also contain a
goal date.
 Following the example above, the expected
outcome would be: Effective airway clearance
as evidenced by normal breath sounds; no
crackles or wheezes; respiration rate 14-
18/min; and no cough by 01/01/01. 3
4. INTERVENTION
 After the goal is set, the nursing interventions
must be established.
 This is the plan of nursing care to be followed to
assist the client in recovery.
 The interventions must be specific, noting how
often it is to be performed, so that any nurses
can read and understand the care plan easily
and follow the directions exactly.
 An example for the patient above would be:
Instruct and assist client to TCDB (turn,
cough, deep breathe) to assist in loosening
and expectoration of mucous every 2 hours. 4
5. EVALUATION
 The evaluation is made on the goal date set.
 It is stated whether or not the client has met the
goal, the evidence of whether or not the goal
was met, and if the care plan is to be continued,
discontinued or modified.
 If the care plan is problem-based and the client
has recovered, the plan would be discontinued.
If the client has not recovered, or if the care plan
was written for a chronic illness or ongoing
problem, it may be continued or sometimes the
nurse should review the step from the beginning.
 If certain interventions are not helping or other
interventions are to be added, the care plan is
modified and continued.
5
 ASSESSMENT DATA PATTERNS
1. Gather all data that leads you to a particular nursing
diagnosis and its resolution and divide this information
into two lists, subjective data or objective data.
2. Remove any information that is NOT directly linked to the
one nursing diagnosis on which you are working.
3. In the Subjective Data list include relevant :
client’s complaints
description of the client's support system
behavioural and nonverbal messages
client awareness of her/his own
abilities / disabilities
disease process
prognosis
health care needs
available resources
1
 ASSESSMENT DATA PATTERNS
4. In the objective data list include relevant:
– physical assessments including vital signs
– observations of the support system in action
– judgment of the client's readiness for learning,
her learning potential, and locus of control
– chart information including lab and test results

2
NURSING DIAGNOSES
1. When writing a plan that includes several
diagnoses, write the diagnosis with the
highest priority first.
2. A plan must start with the major issues for
that client. For example, if the client is in
acute distress over one problem, a plan
covering only other minor problems would
show lack of sensitivity on your part.
3. Select only diagnoses that are appropriate
with resolution by actions you can take.
1
NURSING DIAGNOSES
4. Write out the three parts of the Nursing Diagnosis
(R.E.D.):
– The human Response of the client [wellness response /
problem (anxiety)]
– Etiology or related events / factors, designated as R/T
– Data that is evidence of the diagnosis. You have already
listed this information under Assessment Data Patterns, so
say "as evidenced by the data listed above".

• Note on related factors: Most human responses are

related to several factors. List them all.
For example : anxiety related to
• new environment,
• separation from usual support system,
• big exam in two days 2
CLIENT GOALS
1. Number each goal stating the client Goal, the
Tool to measure goal achievement, and the
Time to evaluate (GTT) :
2. The goal must be stated in terms of client
achievement. ( for example : "The client will
report a reduction in feelings of anxiety")
3. Each goal must be measurable. You must
indicate how you will measure if the goal has
been achieved. ( for example : "as measured
by the client assessing her/his anxiety as less
on a 10 Point Anxiety Scale. It is now 7 on the
10-point scale.")
1
CLIENT GOALS
4. Each goal must state a target date and hour for
evaluation.( The Anxiety Scale will be re administered
in 24 hours : date, hour.)
5. Write at least one "short term goal" for every Nursing
Diagnosis. This will demonstrate your ability to actually
help a client achieve a goal. To get credit for the
Evaluation section of your Care Plan set a time when
you will be there to evaluate goal achievement. ( for
example :" by noon today")
6. Some goals that are important for your client are "long
term goals". Write at least one "long term goal" for
each Nursing Care Plan you develop. Your instructors
understand that this kind of goal will have a time
frame for evaluation that goes past the due date for
the Care Plan. See the section on Evaluation on how to
word the Evaluation of any "long term goal".
2
 EVALUATION OF THE PLAN
1. State when you evaluated the goal. This should be the same
time you designated in the Goal Statement earlier. (for
example : " At noon 2/15/98")
2. Use the measures you designated for goal achievement to
state your client's degree of success. (for example : "the
client evaluated her anxiety as 4 on a 10-point scale.")
3. Draw conclusions on the interventions used related to the
outcome. (for example : "Helping the client to talk about her
feelings reduced her sense of isolation .")
4. Consider changes or additions to the interventions that
might improve goal achievement. (For example: "Studying
with the client before the next examination should reduce
her anxiety even more.")
5. For the "long term goal" you write state: "Evaluation of this
goal is set for (state the date & time). The client has made
(no) (some) (significant)   progress toward this goal : 
(describe any movement toward the goal)."
 VOCABULARY
 Reference (n)  Referensi
 Track (v)  Menelusuri
 Progress (n)  Kemajuan
 Implementation (n)  Implementasi
 ASSESSMENT (n)  Pengkajian
 DIAGNOSIS (n)  Diagnosis
 PLANNING (n)  Perencanaan
 INTERVENTION (n)  Intervensi/tindakan
 EVALUATION (n) kep.
 Current condition (n)  Evaluasi
 Experienced symptom  Kondisi sekarang
(n)  Gejala yg dirasakan
 VOCABULARY
• Blurred vision • Pandangan kabur
• Frequent defecation • Sering BAB
• Frequent urination • Sering BAK
• Dizziness (n)/dizzy (adj.) • Pening
• Rash/red spots • Bintik-2 merah
• Pus • Nanah
• Bioluminescence eyes • Mata berkunang-kunang
• Tightness • Sesak napas
• Shortness of breath • Napas pendek
• Pale (adj.) / pallor (n) • Pucat / kepucatan
• Feverish (adj.) • Pucat
• Fever (n) • Kepucatan
• Jaundice / Icterus • Kekuningan
• Cyanosis • Kebiruan krn kurang O2
• Inflammation • Peradangan
• Swallowing pain • Nyeri telan
• Fatigue / Tiredness • Kelelahan
• Bruise • Memar/lebam
• Numbness (n) / Numb (adj.) • Kesemutan/mati rasa
• Itchy (adj.) / itchiness (n) • Merasa gatal / rasa gatal
• Sunken / hollow eyes (n) • Mata cowong
 VOCABULARY
• Blood sugar / blood glucose = gula
darah
• Gum swelling / inflammation =
bengkak / radang gusi
• Cold sweating = keringat dingin
• Chest pain = nyeri dada
• Hemorrhagic fever = demam berdarah
• Abdominal pain = nyeri lambung
• The wound is healed = lukanya sudah
sembuh
• Pain in the throat = nyeri pada
tenggorokan
• Vomiting and diarrhea = muntaber
• •
Gassiness = kembung
• Nose bleeding = mimisan
• Typhoid abdominalis = Tifus
• Typhoid fever = demam tifus
• Nausea = mual
• Vomiting = muntah
• Chill = menggigil
• Convulsion = kejang
• Back pain = nyeri punggung
• Reddish face = wajah kemerahan
• The face reddens = wajahnya
memerah
• Hollow eyes = mata cowong/sayu
• Thrombocyte decrease =
Penurunan Thrombosit
• Eating pattern = pola makan
• Thirst = kehausan ; thirsty = haus
• Hunger = Lapar ; hungry = lapar
• Wheezing sound = suara khas asma
(ngik-ngik)
• Crackle sound
Intermittent fever = demam yg
datang dan pergi
• Joint pain = nyeri sendi
• MILD – tingkat ringan
• MODERATE – tingkat sedang
• SEVERE – tingkat parah
• Dry mucous area = daerah mukosa
kering
• Fatigue/Weak = lemah lesu
• Appetite loss = hilang napsu makan
• Eat often in smaller amount
(makan sering dgn porsi
sedikit)
• Numb (mati rasa/kesemutan)
• Low-fat food (makanan
rendah lemak)
• High-fiber food (makanan
tinggi serat)
• Vaginal bleeding (pendarahan
di vagina)
• Blood spotting (pendarahan
bercak-2)
• Jaundiced baby (bayi kuning)
• Rash/Petechiae/red spots
(bintik merah)
• Dizziness (pusing)
• Headache (sakit/nyeri kepala)
• Gassiness (kembung)
• Inflammation (peradangan)
• Cyanosis (kebiruan)
• Jaundice (kekuningan)
• Tightness (sesak napas)
• Chest pain (nyeri dada)
• Decrease of appetite (low
appetite) = napsu makan
rendah/menurun
• Fever (demam)
• Pallor (kepucatan)
• Pale (pucat)
• Throat
inflammation/Pharyngitis
(radang tenggorokan)
• Urine retention (sulit BAK)
• Constipation (sembelit)
• Frequent urination (sering
BAK)
• Frequent defecation (sering
BAB)
• Disturbed sleeping pattern
(pola tidur terganggu)
• Eating pattern (pola makan)
• Nausea (mual)
• Vomiting (muntah)
• Edema in the feet
(pembengkakan pd kaki)
• Chest pain (nyeri dada)
• Breast fullness (payudara
terasa penuh)
• Bruise (memar)
• Laceration (luka sayatan)
• Scar (bekas luka)
• Stomachache (sakit perut)
• Abdominal pain (sakit
perut/mulas)
• Bioluminescence eyes (mata
berkunang-kunang)
• My water seeps (air ketuban
saya merembes)
• Blurred vision (pandangan
kabur)
• Itchiness (gatal-gatal)
• Difficulty in breathing (sulit
bernapas)
• Difficulty in
sleeping/sleeping problem
(sulit tidur)
• Cough (batuk)
• Sneezing (bersin-2)
• Sweating (berkeringat)
• Cold sweating (berkeringat
dingin)
• Mastitis (radang payudara)
• Postpartum period (masa
nifas)
• Short umbilical cord
/umbilicus(tali pusat
pendek)
• My water breaks (air
ketuban saya pecah)
 NCP: CHICKEN POX
ASSESSMENT
 SUBJECTIVE:
I have a fever and rashes all over my body
(as verbalized by the patient).
 OBJECTIVE:
•Warm to touch
•Irritability
•Petechiae
•V/S taken as follows:
T: 37.9 P: 93 R: 21 BP: 120/80
NCP: CHICKEN POX
DIAGNOSIS

 Hyperthermia related to viral infection

NCP: CHICKEN POX
INFERENCE
 Chickenpox, also known as varicella, is a highly
contagious and self-limited infection that most
commonly affects children between 5-10 years of
age. The disease has a worldwide distribution and is
reported throughout the year in regions of temperate
climate. The peak incident is generally during the
months of March through May. Lifelong immunity
for chickenpox generally follows the disease. If the
patient's immune system does not totally clear the
body of the virus, it may retreat to skin sensory
nerve cell bodies where it is protected from the
patient's immune system. The disease shingles (also
known as "zoster") represents release of these
viruses down the length of the skin nerve fiber and
produces a characteristic painful rash. Shingles is
most commonly a disease of adults
NCP: CHICKEN POX
PLANNING

 After 8 hours of nursing interventions, the

patient will demonstrate temperature
within normal range and will experience
no associated complications
 NCP: CHICKEN POX
INTERVENTION
 INDEPENDENT:
 Provide isolation or monitor visitors as indicated.
 Wash hands with antibacterial soap before or after care of
the patient.
 Encourage patient to cover mouth and nose during coughs
or sneezes.
 Monitor patient temperature, degree and pattern.
 Observe for chills and profuse diaphoresis.
 Monitor environmental temperature.
 Provide tepid sponge baths, avoiding the use of alcohol.
 Encourage to use calamine lotion.
 COLLABORATIVE:
Administer antipyretics as indicated.
NCP: CHICKEN POX RATIONALE
 Body substance isolation should be used for all
infectious patients and patients with diseases
transmitted through air may also need airborne and
droplet precautions.
 Reduce the risk of spreading the infection. Prevent
the spread of infection via airborne droplet.
 Fever patter aids in the disease process and
diagnosis.
 Precede temperature spikes in presence of
generalized infection.
 Room temperature should be altered to maintain
near-normal body temperature.
 May help reduce the fever.
 To help reduce the itchiness.
 Used to reduce the fever by its central action on the
hypothalamus.
NCP: CHICKEN POX
EVALUATION

 After 8 hours of nursing interventions, the

patient was able to demonstrate
temperature within normal range and
experienced no associated complications.
THANKS for your attention

Practice makes perfect!