Documentation book/Soap notesRegister Today!
- by Esther2007 May 14, '07I am looking for a good documentation/soap notes book. Can someone recommend a good one?
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- May 15, '07 by Daytonite
- May 15, '07 by Esther2007Thank you so much
- May 15, '07 by ED-Adrenalinecheck this out
I tried and I have learned a lot. trust me , they worth the money!
- Jan 5, '09 by herblady6Can you help me please? Is it legal to put the S&O together when doing a soap note. I have seen it done quite often where I work and I remember hearing somewhere that it isn't legal. Do you know if it is or isn't?
- Jan 6, '09 by Daytonitefirst of all, let me clarify for you that the act of documenting, or charting, cannot land you in jail and it is erroneous to refer to the act of charting as being legal or illegal. there are rules to the way a facility may want its employees to document, so they have right and wrong ways for its nurses to chart. soap charting is a type of problem oriented charting method where the following information should be documented for each of the following parts of the note:
- subjective data: chief complaint or other information the patient or family members tell you
- objective data: factual, measurable data, such as observable signs and symptoms, vital signs, or test values
- assessment data: conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses
- plan: strategy for relieving the patient's problems, including short and long term actions
- all of the above comes from page 676 of portable rn: the all-in-one nursing reference, third edition, published by lippincott, williams & wilkins, 2007
s. pt. states, "i feel nauseated." [this is subjective data because it is information that the patient has told the nurse]
o. pt. vomited 100 ml of clear fluid at 2255. [this is objective information because it is data that was observed and measured by the nurse]
a. pt. is nauseated. [this is a conclusion based upon the subjective and objective data]
p. monitor nausea and give antiemetic as necessary. [this is the planned action]