SOAPIER and GPAL

[DawnJ]

When documenting in SOAPIER form, is the GPAL subjective because that is what the patient tells you? Or is it objective regardless of the source of the information? Thanks

[Esme12, ASN, BSN, RN]

I have to tell you that I had to look up SOAPIER....I am sure it is simple but what is GPAL?

SOAPIER:

S:subjective data (what the client or family states)

O: Objective data (what is observed/inspected)

A:assessment (conclusion reached on the basis of data formulated as client problem or nursing diagnosis)

P: plan (expected outcomes and actions to be taken)

SOAPIE and SOAPIER refer to formats that add the following:

I:implementation

E:evaluation

R:revision

[AmyRN303, BSN, RN]

GPAL (gravidity, parity, abortion, living) is something I would consider to be objective data. If the patient gives you an oral medical/surgical history, that is also objective data. SOAPIE/R: I've only ever used SOAP, as each note accounted for further implementation, evaluation and revision.

[Esme12, ASN, BSN, RN]

I knew GPAL is gravidity, parity, abortion, living I thought it might be something else...LOL

[AmyRN303, BSN, RN]

Oh, I know you'd know! I didn't mean to offend.

[Esme12, ASN, BSN, RN]

Oh, I know you'd know! I didn't mean to offend.

No offense taken! I read it and read it and I thought Is that what she is asking. Thank goodness your brain was functional! Mine clearly wasn't....LOL

[Episteme]

When did SOAP notes rise like a zombie from the dead? We were glad to see it go away back in the 70's! Maybe someone found the corpse, dug it up, dressed it in fancy clothes and (having written a book or journal article or presented their "original" idea at a symposium) called it the greatest thing since instant grits... the practice that will solve all medical infomatics problems.

As far as clinicians were concerned SOAP notes were mind-numbingly tedious to write and also to read and were dropped because there was no evidence that they were more effective at communicating clinical information than the traditional narrative note (of that era.)