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SOAP Notes

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by beaRNwhenIgroUP beaRNwhenIgroUP (Member) Member

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howdy folks!

anybody know of a good resource for writing complete, accurate, thorough SOAP notes???

We are expected to do them but nobody has really taught us...

Thanks for any input you might provide...

Sarah:lol2:

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jschut has 20 years experience as a BSN, RN and specializes in A little bit of everything....

2,738 Posts; 18,859 Profile Views

S=subjective data collected from the patient. Things they say is/are going on with them.

EX: fever, stomach pain.....

O=objective data that is "provable".

EX: You take the temp. Is it high? Normal? Is their stomach distended? Hard or soft?

A=assessment is an evaluation of the persons disease or problem based on subjective and objective data.

P=planning is the stragety designed to achieve the care desired for this particular patient.

Hope this helps you out! :)

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131 Posts; 2,241 Profile Views

Thanks Julie...what i am really having problems understanding ishow much info we put under subjective and objective?

if we are doing a complete health history and under musculoskeletal they say they have never had any problem, do i say pt. denies joint pain, stiffness, change in range of motion, etc... all of the questions i ask him / her; OR do i just not mention anything at all since they have no problems there?

or is there some blanket statement that will say the pt. has no problems w/in this system??? e.g. pt denies any changes or problems w/ (blank) system

i hope i don't seem like too much of a ding-dong :rolleyes:

thanks

sarah:devil:

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Love-A-Nurse has 19 years experience and specializes in LTC, ER, ICU,.

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hi bea. look for a pm from me.

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21 Posts; 1,399 Profile Views

I think you only chart abnormals (at minnium)

Unless it is r/t the diagnosis or plan of care

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61 Posts; 2,910 Profile Views

Originally posted by beaRNwhenIgroUP

howdy folks!

 

anybody know of a good resource for writing complete, accurate, thorough SOAP notes???

 

We are expected to do them but nobody has really taught us...

 

Thanks for any input you might provide...

Sarah:lol2:

Try to get your hands on a nursing dx book, usually from Barnes & Noble or Books A Million, they usually have a great nursing section.

Hope this helps.

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131 Posts; 2,241 Profile Views

you guys are great - i think i'm starting to get it - maybe i was just having a blonde moment....

 

it's been a REALLY LOOOONNNNGGGG week!

 

Thanks again,

Sarah:D

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436 Posts; 7,979 Profile Views

hi Sarah:

Bates Guide to Physical Examination and History Taking is a classic

text.

Your school may have a text they recommend for nursing diagnoses(NANDA is popular).

S=Say/Said by patient

O=Observed or Objective(as in measured)

A=your diagnosis

P=plan of treatment

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