N3614 SOAP Charting 2017 PDF

Preview

Summary

How to chart assessment using SOAP...

Description

N3614 SOAP Charting Basic Grading Criteria Please use guidelines below for SOAP charting submissions. This is the basic criteria your LAB Instructors will use as a guideline to base your LAB charting scores on. (As the semester progresses, your LAB Instructor may request you to chart in slightly more detail. Please see them individually for further explanation and details around LAB Week 6). S: Age, gender, ethnicity, reports……… What symptoms does the person say they have? “I have a bad headache” This is a part of your Reason for seeking care. Don’t use CC or Chief Complaint. (O) = Onset?

When first noticed?

(L) = Location? Where is it located? Can you point to the area? (D) = Duration? How long does the symptom last? Is it constant? Is it on and off? (C) = Character? Can you describe the pain? (Sharp, dull, throbbing) Can you the describe the symptom? (A) = Aggravating? What makes it worse? Ameliorating? What makes it better? Associating? What other symptoms are you having with this? (R) = Radiating? Does the pain radiate to any other part of the body? (T) = Timing? What time of the day does it occur? When do you notice it more? (before eating, after eating, after being on the computer) (S) = Severity? Pain? On a scale of 0-10 can you rate your pain? If symptom is nausea, vomiting, coughing etc. is it mild moderate or severe? Once the information has been gathered, you will write your History of Present Illness (HPI) Do not use the actual mnemonic in your write up only the answers to the questions.

Example: This is a 25-year-old female stating “I have a headache” She says the pain began last night after being on the computer for several hours. The pain is located in the front of her head ad radiates into her eyes. She describes the pain as constant and throbbing and says laying in a darkroom helps while bending forward hurts. She rates her pain is a 7 out of 10 (7/10).

O: Objective information obtained during the physical exam: Using medical terms & exact descriptions create an Objective note about each of the systems assessed. Use medical descriptive words such as: symmetric, balanced, midline, equal (in size or shape) medial lateral, etc. Document in a head to toe direction based on the system you assess. You will find examples of physical examination write ups at the end of each chapter. The Vital signs and General survey are contained in the objective portion. A: Assessment is the nursing diagnosis obtained from the subjective and objective data gathered: The nursing diagnosis is the clinical judgement about an actual or potential response to a condition as well as providing diagnosis to support health promotion. These diagnoses apply to individuals, families, groups, and communities. {NANDA International 20152017} formerly known as the North American Nursing Diagnosis Association.

P: Plan is a measurable short or long term goal for the patient based on the nursing diagnosis. These goals support the amelioration of the symptoms the patient is experiencing.

.

(ast 2017)...