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SOAP Charting

SOAP Charting. UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING. Objectives. At the conclusion of this activity, the learner will able to: 1. Document client interaction in a SOAP format. Materials needed. Client Pen/Pencil Paper. SOAP Charting- Definition. S - Subjective

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SOAP Charting

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  1. SOAP Charting UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING

  2. Objectives At the conclusion of this activity, the learner will able to: • 1. Document client interaction in a SOAP format

  3. Materials needed • Client • Pen/Pencil • Paper

  4. SOAP Charting- Definition • S- Subjective “I have fallen down the stairs up to the house two times in the last three months” • O- Objective There are no handrails on steps, steps become icy in the winter. Patient is elderly with poor vision- steps are hard to distinguish • A- Assessment Potential for injury related to decreased home management skills • P- Plan Speak with friends, family, neighbors, service organizations to: put handrails up, scoop steps in winter, and paint bright yellow strip on edge of each stair. Show client how to salt own stairs as needed.

  5. SOAP

  6. Documenting SOAP charting for visit • S -“I am having nausea in the morning and I don’t know what to do about it” • O -Client shifts in seat, appears uncomfortable. Has lost one pound this week. • A -Knowledge deficit related to morning sickness. • P - Offer suggestions to decrease nausea. For example eat a few soda crackers before getting out of bed in the morning. Wendy Wells, RN 10:00AM 5/18/xx

  7. SOAP Charting UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING

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