SOAPIER Documentation

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Fundamentals of Nursing Karteikarten am SOAPIER Documentation, erstellt von SherieChristina am 15/05/2015.
SherieChristina
Karteikarten von SherieChristina, aktualisiert more than 1 year ago
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SOAPIER Definition An acronym for seven different aspects of charting. For notes on specific patient problems, only the necessary parts needed for completeness are used.
SOAPIER (S) S: Subjective information is what the patient states or feels; only the patient can provide this information.
SOAPIER (O) O: Objective information is what the nurse can measure or factually describe.
SOAPIER (A) A: Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need.
SOAPIER (A) A: Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need.
SOAPIER (P) P: Plan is the general statement of the plan of care to be given or action to be taken.
SOAPIER (I) I: Intervention or implementation is the specific care given or action taken.
SOAPIER (E) E: Evaluation is an appraisal of the response and effectiveness of the plan.
SOAPIER (R) R: Revision includes the changes that may be made to the original plan of care.
SOAPE Definitition The briefer adaptation of the charting format for the POMR.
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