What does the acronym for SOAP stand for in nursing?
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When taking care of patients, nurses may be given a huge basket of dirty laundry to wash.They are presented with a lot of different information that needs to be sorted through before carrying out specific interventions.Other health providers can understand and do their part in caring for the patient if the information is documented.
Like separating dirty laundry from clean, nurses use SOAP notes to separate unimportant information from important information.In a neat and organized way, it shows what is happening to patients.It is easier for other healthcare members to understand and care for patients.
S means subjective, or what the patients say about their situation.The patient's complaints, sensations or concerns are included.It's the reason the patient came to see the doctor.Here are a few examples.
O is for what the nurses watch over the patients.Body language and test results are included.When more data is obtained, nurses can conduct a physical examination.Examples include:
A is for assessment or analysis.The nurses make assumptions about what is going on with the patients based on the information they have.These assessments identify important problems or issues that need to be addressed, even though they are not a medical diagnosis.Examples include:
P is for a plan.Depending on the patient's needs and abilities, nurses make decisions about how to provide care.The effectiveness of the interventions can be evaluated if they are realistic and measurable.Treatments, medications, education, and consults to other members of the healthcare team can be included.
Maria had her appendix removed yesterday by the surgeon, Dr. Johnson.Maria complains of a throbbing pain in her abdomen while lying in the hospital bed.Since the surgery, she has been out of bed twice and only eaten 25% of her breakfast.Her husband is by her side.
Patient complains of a throbbing pain in the lower right quadrant of her abdomen with a pain level of 7 out of 10.She said it started hurting this morning.
The patient is due for pain medication according to the medication administration record.Will ask the patient about her pain in 15 minutes.
Nurses use SOAP notes to organize information about patients.The acronym SOAP stands for subjective, objective, assessment and plan.In order to provide clear information to other healthcare professionals, nurses make notes for each of these elements.
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