- 0Nov 17, '11 by SunshineDaisyWe are learning how to do SOAPIE notes, but I am confused on the P. Ok, it's planning, correct? Is that where we put the r/t or the goal? Some sources say yes, some say no. Ack! I'm so confused! Thanks for any help!
- 0Nov 18, '11 by PsychNurseWannaBe, BSN, RNQuote from SunshineDaisyTry this:We are learning how to do SOAPIE notes, but I am confused on the P. Ok, it's planning, correct? Is that where we put the r/t or the goal? Some sources say yes, some say no. Ack! I'm so confused! Thanks for any help!
- 1Nov 21, '11 by GrnTea, BSN, MSN, RNsubjective- this is defined in the dictionary as "
[color=#333333]existing in the mind; [color=#333333]belonging to the thinking subject rather [color=#333333]than [color=#333333]to [color=#333333]the object of thought ( [color=#333333]opposed to objective).
2. pertaining to [color=#333333]or [color=#333333]characteristic of an [color=#333333]individual; personal; individual: a subjective [color=#333333]evaluation." it's the opposite of "objective." in this case, it's the patient's feelings/descriptions of what's going on.
objective is what you find out during your data collection-- your exam findings, lab and xray reports, vital signs, etc
assessment is where you put it all together: what do you think is going on? (don't confuse this with the small-a assessment you perform to collect your data-- different)
plan is what you, the nurse, mean to do about it. you have made one or more nursing diagnoses (that's your assessment of the situation). what's your plan of attack to treat these nursing diagnoses? hint: if you find yourself wanting to say something like, "antibiotics and fluids as ordered," stop right there. we are responsible to deliver the medical plan of care as appropriate, sure, but those items are not nursing plan of care. you are in nursing school to learn how to plan nursing care. this exercise is to help you learn that. plan on doing it a lot.
implementation is your documentation of what happened when you worked your plan, or parts of it.
evaluation is how that worked out for ya, to paraphrase dr. phil (not an md, btw).
so, to do this for a community-acquired pneumonia, you need to have done your data collection and made a decision as to the nursing diagnosis indicated by the data. for that, you go to the nanda and look thru the defining characteristics of various diagnoses until you find one that fits your patient. we can't tell you what that is, because we haven't see him/her. we could make some suggestions about your plan for this diagnosis or diagnoses, but we'd like to see what you come up with first -- we aren't here to do your homework for you, and asking us to does not constitute "research" in the eyes of your faculty:d.
of course, since we don't know what you did, we can't tell you how to document it or how it turned out.
does that help get you started?