Charting - for dummies...

Posted
by sander1x sander1x (New) New

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

nurseprnRN

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

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.

hodgieRN

hodgieRN

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience. 643 Posts

There are some great videos on youtube for clinical assessment if you want a few extra pointers.

Nicole1354

Nicole1354

7 Posts

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)

:)

WoundedBird

WoundedBird

190 Posts

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 says

A - 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!!

nay08

nay08

5 Posts

I thought objective is what you see (observe) and subjective is what the patient says

WoundedBird

WoundedBird

190 Posts

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.

Nicole1354

Nicole1354

7 Posts

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 says

A - 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 :)

bigsick_littlesick

bigsick_littlesick

Specializes in General Surgery. Has 1 years experience. 172 Posts

There's also DAR, Data, Action, Response (pt's). My hospital uses SBAR though, which I like.

nurseprnRN

nurseprnRN, BSN, RN

2 Articles; 5,114 Posts

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?