Charting - for dummies...

  1. 0
    Is there a book out there that will go through a step-by-step assessment and provide you with the typical verbiage used in the clinical setting...

    I can write exactly what I have observed but I would like to be able to document it properly

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  3. 10 Comments...

  4. 1
    Use ADPIE or SOAP-- you can't go wrong c that.
    Also, your faculty should be able to give you sample charting as part of your learning lab experience.
    Esme12 likes this.
  5. 0
    There are some great videos on youtube for clinical assessment if you want a few extra pointers.
  6. 0
    Quote from GrnTea
    Use ADPIE or SOAP-- you can't go wrong c that.
    Also, your faculty should be able to give you sample charting as part of your learning lab experience.
    I'm just curious, what is SOAP. (I'm only 4 weeks into my first semester)

  7. 2
    S - subjective (what you see - swelling, discoloration, deformity, any other 'first impressions' like how they walked in or how they're laying.)
    O - objective (measurements, what the pt reports like pain number and description (sharp, burning...), anything else the pt says
    A - assessment (should be self explanatory, but I've only done athletic training SOAP notes, so I would put my ddx here like wrist sprain vs distal radius fx - not sure how this is done in the nursing world, but ask me in 8 months and I'll know)
    P - plan (what you're going to do immediately, what's already been done, follow up details)

    Hope this helps a bit!!
    turnforthenurseRN and Esme12 like this.
  8. 1
    Esme12 likes this.
  9. 0
    I thought objective is what you see (observe) and subjective is what the patient says
  10. 0
    I think I did flip S and O around now that I did a mock SOAP note in my head for the first time in 6+ months. Sorry about that...had a looong week.
  11. 0
    Quote from KAR813
    S - subjective (what you see - swelling, discoloration, deformity, any other 'first impressions' like how they walked in or how they're laying.)
    O - objective (measurements, what the pt reports like pain number and description (sharp, burning...), anything else the pt says
    A - assessment (should be self explanatory, but I've only done athletic training SOAP notes, so I would put my ddx here like wrist sprain vs distal radius fx - not sure how this is done in the nursing world, but ask me in 8 months and I'll know)
    P - plan (what you're going to do immediately, what's already been done, follow up details)

    Hope this helps a bit!!
    Thanks so much
  12. 1
    There's also DAR, Data, Action, Response (pt's). My hospital uses SBAR though, which I like.
    Esme12 likes this.


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