SOAP Notes

jschut, BSN, RN · Sep 21, 2002

S=subjective data collected from the patient. Things they say is/are going on with them.

EX: fever, stomach pain.....

O=objective data that is "provable".

EX: You take the temp. Is it high? Normal? Is their stomach distended? Hard or soft?

A=assessment is an evaluation of the persons disease or problem based on subjective and objective data.

P=planning is the stragety designed to achieve the care desired for this particular patient.

Hope this helps you out! :)

beaRNwhenIgroUP · Sep 21, 2002

Thanks Julie...what i am really having problems understanding ishow much info we put under subjective and objective?

if we are doing a complete health history and under musculoskeletal they say they have never had any problem, do i say pt. denies joint pain, stiffness, change in range of motion, etc... all of the questions i ask him / her; OR do i just not mention anything at all since they have no problems there?

or is there some blanket statement that will say the pt. has no problems w/in this system??? e.g. pt denies any changes or problems w/ (blank) system

i hope i don't seem like too much of a ding-dong :rolleyes:

thanks

sarah:devil:

Love-A-Nurse · Sep 21, 2002

hi bea. look for a pm from me.

roud123 · Sep 22, 2002

I think you only chart abnormals (at minnium)

Unless it is r/t the diagnosis or plan of care

LPN & EMT-CT · Sep 22, 2002

Originally posted by beaRNwhenIgroUP
howdy folks!

anybody know of a good resource for writing complete, accurate, thorough SOAP notes???

We are expected to do them but nobody has really taught us...

Thanks for any input you might provide...
Sarah:lol2:

Try to get your hands on a nursing dx book, usually from Barnes & Noble or Books A Million, they usually have a great nursing section.

Hope this helps.

beaRNwhenIgroUP · Sep 22, 2002

you guys are great - i think i'm starting to get it - maybe i was just having a blonde moment....

it's been a REALLY LOOOONNNNGGGG week!

Thanks again,

Sarah:D

globalRN · Sep 28, 2002

hi Sarah:

Bates Guide to Physical Examination and History Taking is a classic

text.

Your school may have a text they recommend for nursing diagnoses(NANDA is popular).

S=Say/Said by patient

O=Observed or Objective(as in measured)

A=your diagnosis

P=plan of treatment