INTRODUCTION OF NURSING 1.4 The Nursing Process (PART 3)

SOAP Notes - Assessment













• Elements include the following.


➢Problem

✓List the problem list in order of importance. A problem is often known as a


diagnosis.


➢Differential Diagnosis


➢This is a list of the different possible diagnosis, from most to least likely, and the

thought process behind this list. This is where the decision-making process is

explained in depth. Included should be the possibility of other diagnoses that may

harm the patient, but are less likely.


➢Example: Problem 1, Differential Diagnoses, Discussion, Plan for problem 1

(described in the plan below). Repeat for additional problems 51

SOAP Notes - Plan

















• This section details the need for additional testing and


consultation with other clinicians to address the patient's


illnesses.








• It also addresses any additional steps being taken to treat the

patient.








52

SOAP Notes - Plan

















• This section helps future physicians understand what needs to be


done next. For each problem:


➢State which testing is needed and the rationale for choosing


each test to resolve diagnostic ambiguities; ideally what the


next step would be if positive or negative


➢Therapy needed (medications)



➢Specialist referral(s) or consults


➢Patient education, counselling 53

PIE Notes


















• P-problem-disease process (whats going on with your patient at

assessment)








• I-intervention-what you did to assist or implement to eleviate the


problem at hand








• E-evaluation- how your intervention worked

54

PIE Notes














• Do your patient assessment:


• ie: Patient admitted with SOB, noted o2 sats at 85% on room air






P - SOB,sats


I - O2 started at - dosage, Dr notified , restrictive clothing removed , Dr


notified awaiting orders

E - sats >90, no complaints of SOB at this time, Orders from Dr received.


Patient denies discomfort and sob at this time will continue to evaluate


status.

55
• Put each situation into the PIE.

PIE Notes














Another example







P: O2 requirement







I: Weaned O2 today, increased Lasix dose.







E: Tol well, no distress, PO greater than 95%. No s/s of CHF, had good output

from increased Lasix. Cont to wean O2 as able, follow pulseoxy and follow for

further s/s of CHF. 56

Focus Charting


















Three columns are
usually used in
Focus Charting for

documentation:











Date and Hour Focus Progress Notes








57

Focus Charting





















Intended to make Method or




the client concerns organizing health



and strengths the information in an



focus of care individual’s record













58

Focus Charting









• example of a format of Focus Charting





Date/Hour Focus Progress Notes


3/7/2010 Focus of care, this may •Data


8:00pm be:a nursing diagnosis •Action

a sign or a symptom •Response


an acute change in the

condition


behavior














59

Charting By Exception





















A system for documenting

exceptions to normal illness or Based on preestablished guidelines,

disease progression, using a protocols, and procedures that

shorthand method of charting identify and document the standard
what's usual and normal. You make patient management and care

check marks or write your initials in

certain places on the CBE flow delivery.

sheets.





60

Case Management Models






















A critical pathway is a


multidisciplinary plan or tool
A methodology for organizing
that specifies assessments,
client care through an illness, interventions, treatments and

using a critical pathway.
outcomes of health related

problems a cross a time line.







61

Electronic Documentation
























Increases the
Facilitates
quality of Increases legibility statistical analysis


documentation and accuracy. of data.

and save time.











62

63

64

65

66

References

















• https://books.google.com.my/books?id=dAIHuCJyaVoC&pg=PA21&lpg=PA21&dq=Focus+Charti

ng+documentation+format&source=bl&ots=_RRWP_SgvZ&sig=ACfU3U0YZCEgMN58zR7ipo5cIu
Jzd1QfoA&hl=en&sa=X#v=onepage&q=Focus%20Charting%20documentation%20format&f=fals

e





• https://books.google.com.my/books?id=m1fPFVJIi6gC&pg=PA70&dq=Focus+Charting+documen

tation+format&hl=en&sa=X&ved=0ahUKEwj26-

rvr4fnAhUYcCsKHaY9BgoQ6AEIMDAB#v=onepage&q=Focus%20Charting%20documentation%2
0format&f=false






67