I'm fairly new to school nursing. I need some help with soap charting and what to put in the A part. Do I just put whatever nursing diagnosis from that big list from nursing school or is there a guide that can help school nurses with this? I come from a hospital setting and I haven't had to do this in a long time. Thanks!!!
Mar 28, '12
For the "S" (subjective) you include everything the student/patient tells you about their problem. I often use exact quotes.
"O" (objective) - Everything you observe while they are speaking to you.
"A" (assessment) - You nursing assessment
documentation often broken down into systems. I usually include my objective observations and assessment under the same label.
"P" (plan) - Any interventions you provide for the student. (water, rest, calling parents, etc.) I include everything I told parents when I spoke to them and their comments and/or them verbalizing understanding. This way if something comes up later, I can check my documentation on what we discussed.
I hope this helps.