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 0 Likes
nurseprnRN, BSN, RN 2 Articles; 5,114 Posts Feb 8, 2013 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. 0 Likes
hodgieRN Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience. 643 Posts Feb 9, 2013 There are some great videos on youtube for clinical assessment if you want a few extra pointers. 0 Likes
Nicole1354 7 Posts Feb 9, 2013 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) :) 0 Likes
WoundedBird 190 Posts Feb 9, 2013 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 saysA - 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!! 0 Likes
mariebailey, MSN, RN 948 Posts Feb 9, 2013 Here are some resources:CNE on charting: Document It Right: Would Your Charting Stand Up to Scrutiny? | CE510 > Continuing Education Unit at Nurse.comCNE on charting: Document It Right: A Nurse's Guide to Charting | 60076 > Continuing Education Unit at Nurse.comDo not use abbreviation list: http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf 0 Likes
nay08 5 Posts Feb 9, 2013 I thought objective is what you see (observe) and subjective is what the patient says 0 Likes
WoundedBird 190 Posts Feb 9, 2013 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. 0 Likes
Nicole1354 7 Posts Feb 9, 2013 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 saysA - 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 :) 0 Likes
bigsick_littlesick Specializes in General Surgery. Has 1 years experience. 172 Posts Feb 10, 2013 There's also DAR, Data, Action, Response (pt's). My hospital uses SBAR though, which I like. 0 Likes
nurseprnRN, BSN, RN 2 Articles; 5,114 Posts Feb 11, 2013 Subjective: These are feelings, opinions. "Pt states he feels weak and dizzy and has pain in LUQ." "Mother says baby isn't feeding well." "Cat isn't grooming herself, paces as if she has pain." (Guess what I've been doing the last month... )Objective: Data that can be measured-- VS, physical examination findings, labs, diagnostic imaging, I&O, etc.Assessment: So, whaddaya think about all that? What's your diagnosis?Plan: And what are you going to do about it? 0 Likes
