SOAP charting Essay Example | Topics and Well Written Essays

"SOAP Charting and How Nurses Can Use It for Documentation" is a worthy example of a paper on care.
SOAP simply means: Subjective, observations, assessments, and planning

SOAP Charting Format
SOAP notes are a way through which documentation can be done.
This paper looks at the importance of Soap charting and how nurses can use it for documentation.
SOAP notes happen to be quite necessary.
SOAP documentation happens to be a problem-oriented technique within which a nurse will identify as well as list the health concerns of patients.
Charting subjective matters, observations, and assessments not forgetting medication plans is a crucial part of the nursing practice.
They are highly relied upon by nurses as well as other professions too.
SOAP documentation breaks the documentation process into four different categories which include Subjective, observations, assessments, and plan.
Each of these categories needs to be considered or proper documentation (Mary).
Documentation using SOAP notes can be done as follows:
S= Subjective Data
These are notes on the feelings or experiences of the patient, the time frame within which this has been an issue, the frequency, duration, intensity, through what does it become better or worse, family history, any past history, results of home monitoring ( weight, BP, glucose monitoring), etc.
O= Objective Data
In this category, information documented includes the physical exam results, what are the observations of the nurse, relevant fundamental signs among other observations.
Techniques that were applied in course of the session should be recorded.
Observations also include visual observations as well as physical findings that were discovered while palpating the body of the client or any other method used to acquire useful information about the client.
Things observed by a nurse concerning the posture of the client, weakness, movement, tension level within the tissues, movement of joints, spasms within muscles, skin temperature as well as color and breathing patterns as well (Service).
A= Assessment
This section records what is the medical diagnosis or nursing diagnosis (for the problem in existence), problem identification, etc.
This category is for reporting the session’s immediate results.
After the treatment is done, the nurse needs to reanalyze the posture as well as a range of motion and then make notes on whatever changes within symptoms using a lot of descriptive words (physiciansoapnotes.com).
P= Plan
Data recorded in this category include: what interventions were done while seeing the patient, the follow-up, the medications that have been changed or prescribed, further required investigations as well as tests, what time the patient will be seen again, among others.
After treatment, a nurse needs to suggest a frequency of treatment as well as other matters, which would require to be addressed as time goes by, in the treatment plan.
This may include any special client requests as well as reminders and self-care instructions that are given to the patient (Mary).
Documentation
One can document SOAP notes electronically or manually.
Paper SOAP notes could be hard to reread as well as the abbreviations could be inconsistent.
With SOAP notes, a diligent filling system is necessary and the notes should be correctly filled.
A web based charting program may also be used for SOAP notes documentation.
It assists in the elimination of difficult paper filling of paper SOAP notes.
Proper Documentation will protect nurses, increase professionalism as well as ensure care for patient excellent continuity.

SOAP Charting and How Nurses Can Use It for Documentation - Essay Example

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