Soapie (Psych) note - good PDF

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S.O.A.P.I.E. NOTE

DATE ___________________________

CLIENT’S INITIALS ________________

NAME ___________________________

ADMITTING DIAGNOSIS _____________________________________________________________________________________ _____________________________________________________________________________________

S = SUBJECTIVE: Chief complaint, suicidal (thoughts, plan, means), Reports of Hallucinations _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

O= OBJECTIVE/ASSESSMENT: Vital Signs, Appearance, Nourishment, Ability to Care for Self, State of Consciousness, Mood/Affect, Speech, Thought process (Content/Flow of Thought), Observance of Audio/Visual Hallucinations, Insight, Judgment, Detox Signs/Symptoms _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

PRIORITY NURSING DIAGNOSIS: _____________________________________________________________________________________ _____________________________________________________________________________________

P = PLAN(S): This is always what you plan to do to address the issues that you have discovered. They are always evidence-based and be realistic. What can YOU do while there with the patient. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

I= INTERVENTIONS: What are the nursing interventions that you would implement for this client to achieve your plan? These are always evidence-based.

E = EVALUATION: How well did the planned interventions work, what was the result? Do we need to go back, reassess what we did, and create a new or modified plan? Should plan continue?

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