Narrative Notes and Soap Notes HELP!!!

If you do a search from this student forum (used advanced search) for "charting" (use the drop down box for "in title only") there's a really cool thread that actually has some good tips and one that has a snippit from the charting made easy book. (I actually copied that one out and carry it in case I go brain dead during clinical and can't think of the "duh" things)

HTH ...sorry I can't be more expicit myself but that one post really has a great example.

btw it's the thread that starts out with "narrative charting" and by sports...

S=subjective data what the patient says "chest hurts"

O=objective data what you observe -patient grimacing holding chest

A= Assessment data bp 176/65 hr 122 rr24 etc

P=Plan what will you do with data you found. Gave 1 sl Ntg tab, informed physician, etc.

Hope this helps

Our SOAP notes are assignments we turn in, and the "A" is where we put our nursing diagnosis. The plan section is our goals, and if we aren't including "IE" we'd put planned interventions there too.

Our SOAP notes are assignments we turn in, and the "A" is where we put our nursing diagnosis. The plan section is our goals, and if we aren't including "IE" we'd put planned interventions there too.

Actually, that is correct. I see a lot of confusion over the "A". Many people go back and list more of some type of assessment data (like v/s or for some reason another head to toe which would actually go under the "O" for objective data). Think of the word assessment not as in "head to toe" but as in "opinion" i.e. "What is your assessment (opinion/dx) of this situation?". So a DX of some sort is appropriate, or some providers put their "impression" here. What I tell my students is this:

subjective (S) + objective (O) = assessment (A)

and then of course you have plan (P) which is for goals, interventions both planed and completed like "placed on O2"

Example (brief):

Subjective: pt c/o SOB, denies CP, dizziness, n/v, fever, chills, states hx of asthma and current SOB is consistent with her asthma attacks.

Objective: L/S wheezes, ins/exp in all fields, no visible trauma, deformity, discoloration, v/s BP 120/88, HR 118, RR 26 T 37.1

Assessment: impaired gas exchange r/t bronchospasm

Plan: Provide O2, albuterol neb, keep sats above 93 percent

This is a type of documentation that physicians developed a long type of ago that has spread out to other groups like nurses and paramedics (who use this type quite often).