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Documentation book/Soap notes

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by Esther2007 Esther2007 (Member)

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I am looking for a good documentation/soap notes book. Can someone recommend a good one?

Thanks

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herblady6 specializes in Handicapped.

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Can you help me please? Is it legal to put the S&O together when doing a soap note. I have seen it done quite often where I work and I remember hearing somewhere that it isn't legal. Do you know if it is or isn't?

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Daytonite is a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

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first of all, let me clarify for you that the act of documenting, or charting, cannot land you in jail and it is erroneous to refer to the act of charting as being legal or illegal. there are rules to the way a facility may want its employees to document, so they have right and wrong ways for its nurses to chart. soap charting is a type of problem oriented charting method where the following information should be documented for each of the following parts of the note:

  • subjective data: chief complaint or other information the patient or family members tell you
  • objective data: factual, measurable data, such as observable signs and symptoms, vital signs, or test values
  • assessment data: conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses
  • plan: strategy for relieving the patient's problems, including short and long term actions
    • all of the above comes from page 676 of portable rn: the all-in-one nursing reference, third edition, published by lippincott, williams & wilkins, 2007

as you can see, s (subjective) data and o (objective) data each have their own specific place in the soap charting method, so, no they should not be combined together when writing a soap note. they should be distinctively separate from each other as in the example below from page 677 of the above reference:

s. pt. states, "i feel nauseated." [this is subjective data because it is information that the patient has told the nurse]

o. pt. vomited 100 ml of clear fluid at 2255. [this is objective information because it is data that was observed and measured by the nurse]

a. pt. is nauseated. [this is a conclusion based upon the subjective and objective data]

p. monitor nausea and give antiemetic as necessary. [this is the planned action]

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