Part I
SOAP Charts
SOAP note in nursing is an acronym for Subjective, Objective,Assessment, and Plan. The concept of SOAP note was introduced by Dr. Lawrence Weed as POMR (Problem Oriented Medical Record) in the 1970s. He did this to standardized medical documentation. On top of this, it offers a frmawork for the evaluation of information as well as a cognitive framework for logic reasoning by the medical providers. Since its release, its popularity has grown tremendously as many aspects of modern health care are SOAP charts’ byproduct.
How To Use SOAP Charts
In making clinical judgments that will outperform the standards set for patient care, it is critical to take organized and complete notes of the patients. Through SOAP charts, this is achieved; as it enables the collection of important pieces of data in regards to the health position of the patient. In using the SOAP chart, the four components of the acronym are broken down and dealt with separately.
The first part is the collection of patient health status information as stipulated by SOAP chart is “Subjetive.” This section seeks subjective information, such as personal views, feelings and experience. According to Podder et al. (2020), this section entails three broad subsections; chief complaint, history, and review of systems. Chief complaint (CC) should be presented by the patient and ighlights the reasons why the patient has sought medical advice. Information that the patient might address includes a condition, symptom, or previous diagnosis. The specific examples are headache, lack of sleep, among others. Although the patient state numerous complaints, it is recommended that the providers be able to identify the key problem and effectively manage it. Concerning the patient’s history Podder et al., (2020) point out the best way to get an in-depth history is by asking questions by following “OLDCARTS.” This too is an acronym for Onset, location, duration, characterization, alleviating (or aggravating) factors, radiation, temporal factor and severity. The first three, alleviating or aggravating factors, and severity are straightforward. Characterization is how the CC is described by the patient; radiation is whether the CC is mobile; while temporal factor seeks to determine if the CC improves or worsens at specific periods. Finally, the review of systems attemps to obtain information that might be left out. Mostyly the symptoms, allergies and current medication.
Folowing the “Subjective” section is the “Objective.” This part drifts away from subjective data, and instead, deals withobjective data. This includes data from the laboratory, vital signs, imaing, physical examination and other diagnostic data.
The third section in using SOAP chart is “Assessment.” Here, elathcare proiders utilize data from the two previous sections to reach at a diagnosis.
The final ection is “Plan.” This part details how the clinical personel wil address the problem (patient illness or condition).
PIE Charts
PIE charts is an alternative form for ducomenting patients’ health status, though it is now widespread. It is till too an arnym for Problem, Intervention and Evaluation.In general, “P” is the problem that needs to be addressed together with the plan, “I” is the implementation of the plan, while “E” involves evaluating the plan and identifyinh its efficacy.
How To Use
Nurses planning to use the PIE chart shoulf follow it chronologically – P, I, then, lastly E. To identify and consequrntly arrive to a management approach (which is section “P”), the clinicians must do an assessment, then diagnosis. Here, the speciliast will establish a database that includeds both subjective and objective data. The roles to be played are the collection, organization, validation and documentation of the data of the client. After this, the diagnosis will follow. In this part, the clinician ough to deveolop collaborative problems and a list of diagnoses. To do this, he will need to successfully interpret and analyze the data – comparing it against set guidelines, grouping and determining inconsistencies and gaps. The last section in “P” is planning. Prior in making of a plan, the stregths, risks and problems should be well defined. The plan will therefore include ways of prevetion, reduction or resolution of the problems of the client. Also, the implementation of the intervention in a mannar that is individualized, organized and goal-oriented.
The second section of PIE chart is “I” or the plan implementation phase. Overall, the aim of this saction is to help the client in meeting the desired outcomes, and stimulate coping with transformed functioning. The steps to take are: first is selecting the aproprate inteverntion delegate (or perform is nursing assistance is essential) nursing intervention, and communicate deeply the nursing actions undertaken. Due to documentation purposes, the nurse is supposed to document the care and lient resposnes.
In concluding the PIE chart, the nurse should measure the magnitude to which the goals have been realized, and also not factors that facilitating or hindering the realization (section “E”). To do this, the nurse will collobaritevly engage with the patient and if the goals have not been met, a re-evaluation is a prerequisite. The reevaluation process will involve analyzing if data collection was enough, diagnosis was carried accurately, etiology is precise, intervention is realistic and outcome measurability and whether it is patient centered.
Improvement in SOAP and PIE Charts
A research ound that the ordering of the SOAP to APSO was much better in terms of task success, speed, and usability during the acquisition of information by a physician pertaining to a chronic disease. Additionally, in an ongoing care, the reanged form of SOAP (APSO) is more superior than its typical form It is because providers locate faster the assessment and plan of their colleagues’.
To improve the conveyance of information in both of the chrts, healthcare proiders should counter-check the descriptions. It encompasses a detailed examination of the situation and the treatment plan advocated to the patient. The common that exist is in the noting down of the chief problem (or CC in SOAP). Many practitioners tend to report the general cause. For instance, hen they record that the problem is injury (which is wrong). They should be specific and state, there is a pain in the left lower arm. Overall, for proper conveyance of the patient’s information on top of detailed description, is that abbreviations that ar not professional, and grammar and spelling errors should be avoided
Part II
Part III