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how to make a SOAPIE note

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can someone tell me how to make SOAPIE notes?
I don't ever see SOAPIE used in nursing anymore. Sometimes physicians will use that format.S= subjective findingsO= objective findingsA= assessmentP= planI= interventionsE= evaluationIs there a particular problem that you're encountering?

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Subjective-This is what the patient is saying about how they're feeling.Objective-This is what you are observing is happening.Assessment-This is your assessment-usually all the head to toe stuff in addition to your observations of the patient's problem.Plan-This is what you plan to do for that patient r/t the problem and overall care, and the goals for the patient.Implement-This is what you've done.Evaluation-This is whether the care so far has been effective in helping the patient reach the goals

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Quote from EricEnfermeroI don't ever see SOAPIE used in nursing anymore. Sometimes physicians will use that format.S= subjective findingsO= objective findingsA= assessmentP= planI= interventionsE= evaluationIs there a particular problem that you're encountering?

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thanks for the reply........

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soapie charting is:"s (subjective data) - chief complaint or other information the patient or family members tell you.o (objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values.a (assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.p (plan) - strategy for relieving the patient's problems, including short- and long-term actions.i (interventions) - measures you've taken to achieve expected outcomes.e (evaluation) - analysis of the effectiveness of your interventions.r (revision) - changes from the original care plan"(this information is from page 676 of portable rn: the all-in-one nursing reference, third edition, published by lippincott, williams & wilkins, 2007)

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I hate SOAPIE. We use 'Systems', incorporating other wholistic concerns as well. What are the common ways of documenting in the US?

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could you help how to make SOAPIE for pediatric community acquired pneumonia? thanks
Author: peter  3-06-2015, 16:34   Views: 1490   
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