Originally Posted by MB37
Our SOAP notes are assignments we turn in, and the "A" is where we put our nursing diagnosis. The plan section is our goals, and if we aren't including "IE" we'd put planned interventions there too.
Actually, that is correct. I see a lot of confusion over the "A". Many people go back and list more of some type of assessment data (like v/s or for some reason another head to toe which would actually go under the "O" for objective data). Think of the word assessment not as in "head to toe" but as in "opinion" i.e. "What is your assessment (opinion/dx) of this situation?". So a DX of some sort is appropriate, or some providers put their "impression" here. What I tell my students is this:
subjective (S) + objective (O) = assessment (A)
and then of course you have plan (P) which is for goals, interventions both planed and completed like "placed on O2"
Example (brief):
Subjective: pt c/o SOB, denies CP, dizziness, n/v, fever, chills, states hx of asthma and current SOB is consistent with her asthma attacks.
Objective: L/S wheezes, ins/exp in all fields, no visible trauma, deformity, discoloration, v/s BP 120/88, HR 118, RR 26 T 37.1
Assessment: impaired gas exchange r/t bronchospasm
Plan: Provide O2, albuterol neb, keep sats above 93 percent
This is a type of documentation that physicians developed a long type of ago that has spread out to other groups like nurses and paramedics (who use this type quite often).
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