SOAP Note Example | Nursing SOAP Note
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- Опубликовано: 6 июл 2024
- SOAP Note Example | Nursing SOAP Note
In this video we're going to go through the different types of nursing notes, specifically SOAP, SOAPIE and SOAPIER notes. We will walk through examples, and after this video you will know exactly what a SOAP note is in nursing school and how to write an awesome one. Trust me, you will seriously impress your clinical instructor.
SOAP, SOAPIE, or SOAPIER charting are all very straightforward and to the point, and they are all very similar.
SOAPIER:
SOAP, SOAPIE and SOAPIER stand for: Subjective, objective, assessment, plan, Intervention, evaluation and revision.
Subjective: The subjective portion goes over what the patient is saying or feeling as told by them. Something you can't measure, but is based on how the patient is feeling or their opinion.
Objective: This is the part that states the facts, the values that can be measured. This would be the vital signs, lab results, test results, things that are measurable.
Assessment: This is the area where you put your findings as the nurse. So what you are observing, or what the patient tells you.
Plan: The part where you get to show off what you did or plan to do as the nurse to help your patient.
Intervention: This is where you show off what you did or will do to help you patient.
Evaluation: This is where you validate that you actually helped your patient.
Reassessing, Revision, or Review: Based on your evaluation, you would document any changes that you would make in order to improve the outcome.
So again, these are all used, and it will be specific to your program which they prefer you learn, but the acronyms stand for the same things, SOAPIER stands for Subjective, objective, assessment, plan, Intervention, evaluation and revision.
You are doing an amazing job, friend! You will be an outstanding nurse that God created only you to be.
TIMESTAMPS:
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0:57 Definition
2:38 Deep dive
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