psych soap charting

[lotus31]

Hi Everyone,

I need help. In our psych rotation we are SOAP charting. I am used to narrative charting. I am having the worst time in the world trying to formulate the assessment. I've read my text, careplan books, etc and its still not helping. I can't keep my personal feelings out of the assessment. Have I mentioned that psych patients terrify me? Any input, advice or info would be helpful.

lotus31

[cmo421]

Hi Everyone,

I need help. In our psych rotation we are SOAP charting. I am used to narrative charting. I am having the worst time in the world trying to formulate the assessment. I've read my text, careplan books, etc and its still not helping. I can't keep my personal feelings out of the assessment. Have I mentioned that psych patients terrify me? Any input, advice or info would be helpful.

lotus31

http://cpmcnet.columbia.edu/dept/ps/2002/SOAPintro.html

This is a helpful site. Psych is hard, not my bag . I always find it helpful to read others notes to gain insite and ideas as to what the facility expects. I love narrative notes, but they are not widely used an ymore. I have found that soap and pie notes are becong more vogue in my area. With new flow sheets , many notes are shorter and easier to write. Good luck!

Subjective data; what you are told by the pt.

Objective data; what you see/hear/feel/smell

Assessment; your nursing diagnosis

Plan; what you did or whats in progress of being done

[Daytonite, BSN, RN]

i recommend you look among the links on the health assessment resources, techniques, and forms in nursing student assistance forum (https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html) for a link to a psych or mental health assessment form or guideline that you can use to help you out with your wording of the assessment.

these are links on how to write a soap note:

• http://www.awarenessproductions.com/doc_ed_pages/soap.htm - soap format, strengths and weaknesses
  
• http://www.medicalassistant.net/soap_note.htm - writing soap notes. includes links to sample soap notes at the bottom of the page.
  
• http://en.wikipedia.org/wiki/soap_note - soap note

[lotus31]

Thanks so much for those links. It really makes a difference seeing what an actual note looks like.

lotus31

[emmase10]

Great advice!

[EarthChild1130]

At the place where I work now we use SOAP for charting, and at first I had NO clue what I was doing, but it's second nature now...it gets easier as you use it...good luck!

[Wisdomlife healer]

Hello Everyone,

New to allnurses.com, found the information "very helpful". I am a nursing student (Senior) and needed therapuetic comm. help for a psych dialouge, when I came across this site in Google. Good to see the nurses here are not "eatting their young", had that experience once or twice while in clinicals. Being the mature nursing student, I found my education to be very broad, accurate (skills needed) and sometimes a "customer service nightmare". Still motivated inspite of the negatives and looking forward to being a member of the few, the proud and compassionate members of society that care enough to invest in this field.

Currently working as a nurse tech in a midsize hospital, which has helped in both using skills, developing confidence and comfort level with patients and staff, so those who are considering working in the hospital prior to graduation, I strongly encourage you to do so ( at least prn).

Again, thank you for the suggestions and where to find info! :redbeathe