I Need Info About Soapie

[hera1021]

Hello everyone!!!!

I need info about SOAPIE. I would like to know if there is a book reference, template or software that help me how to write an excellent nursing note, using only SOAPIE note. I really appreacite your help.

Thanks;

Hera1021

[TexasPediRN]

Well I've never used a SOAPIE note, but we did learn the SOAP note in nursing school, is that what you are referring to?

If so its

(S) ubjective - what the patient tells you (this hurts, im nauseated)

(O) bjective - what you can see/measure (vital signs, etc)

(A)ssessment - self explainatory (lungs clear, surgical dressing intact or covered with dried blood)

(P)lan - what do you plan on doing now that you know the patient is/is not in pain and you have completed your assessment?

I dont think there is any software to write a SOAP note. I would venture to guess that the (I) is for Implementation and the (E) is for evaluation.

If so (I)mpelmentation - gave pain medication, provided a warm compress

(E)valuation - pt in less pain, rates at 6 now instead of 10 30 min later, cool compress resolved slight fever, pts temp now 98.6 instead of 99.1.

Practice makes perfect :) Thats the best way to learn.

Does that help??

[meownsmile, BSN, RN]

I dont know that SOAPIE charting is used much anymore with computers being used.

[alronred]

Hello everyone!!!!

I need info about SOAPIE. I would like to know if there is a book reference, template or software that help me how to write an excellent nursing note, using only SOAPIE note. I really appreacite your help.

Thanks;

Hera1021

Bro there i a book titled Nurse's Pocket Guide or what we so called 'NANDA' here in the Philippines. It will help you a lot in forming a diagnosis/SOAPIE for your client.