One of the most important parts of a nurse’s job is accurate, descriptive documentation. While a lot of charting that nurses do is “charting by exception” in an electronic medical record (EMR), there are plenty of scenarios in which a nurse will need to “free-write” nursing notes. It can be difficult to write a nursing note in an organized and detailed manner, and there are several strategies taught to nurses to ensure that their documentation is effective. In this article, the SOAP or SOAPIE method will be described.
Importance of Documentation
Nurses spend a lot of time charting/documenting throughout their shifts. There is a saying amongst nurses, “if it wasn’t charted, then it didn’t happen.” Nurses must document every single thing they do for their patients throughout their shifts, including conversations and communication. Primarily, documentation will consist of charting nursing assessment findings and nursing interventions or cares, though nurses also need to document phone calls with patients, provider’s verbal orders, and anything out of the ordinary that has happened throughout the shift. Doing so will help protect nurses as an employee and will ensure that proper care is given to patients and communicated with other caregivers and providers.
To help with accurate and thorough documentation skills, try following the SOAPIE method. There is an older version of SOAPIE notes, which are SOAP notes.
Subjective –Documentation should include what the patient says or information that only the patient can provide personally. This should include perceived pain, symptoms such as feelings of numbness or tingling, medical and family history, and allergies. This information is gathered through asking the patient questions and is important to record exactly as the patient reports.
Objective – Record what the nurse observes, hears, sees, and feels during the patient assessment. The types of assessments performed is dependent on the facility the patient is in (inpatient versus outpatient) and on the medical diagnoses and patient complaints.
Analysis – After subjective and objective assessment data is collected, the nurse should make an initial analysis of the patient’s condition and identify any appropriate nursing diagnoses.
Plan – Once an initial nursing diagnosis has been identified, the nurse must create a plan of action. This may include repositioning, requesting pain medication from the providers, applying oxygen per protocol, or providing emotional support. The plan should be patient-centered and based on the nursing diagnoses.
Implementation – After the plan of action has been decided, the actions (interventions) should be put into motion. Sometimes, a nurse’s plan does not go exactly as planned and that is to be expected. It is important to document all of the interventions performed, and even the ones that were attempted.
Evaluation – Finally, the outcomes of the interventions need to be evaluated. The evaluation often includes reassessing the patient. If the evaluation reveals that an intervention did not work, a different plan may need to be made. Repeat the last few steps as necessary until a satisfactory outcome is reached.
When Should You Document?
Different types of documentation are completed are varying intervals. For example, some documentation, like fall risk or physical assessments, only need to be done once a shift. However, other assessments, such as for pain, should be done regularly throughout the shift as needed. Other regular documentation should be taken upon intake, at the change of a shift, when a patient is discharged, when they return from a test or procedure, and any time a change in patient condition occurs.
Some nurses find it difficult to set aside time routinely during their shift to document, especially during shifts that are busier than usual. However, it is a crucial part of good nursing and quality patient care. If you’re having a hard time remembering to document or setting aside time for it, try setting a timer or scheduling time for yourself during a shift to spend at least 10 minutes documenting. It is easier to document as you go throughout your shift, then try to remember everything at the end of a long shift. Unfortunately, waiting until the very end of a shift to do all the required documentation can result in documentation errors.
SOAPIE Nursing Notes Examples
Example 1:
Subjective – Patient M.R. is a 68 year old male with no known allergies who presented to the ED two days ago with intermittent chest pain that had been lasting for 5 hours. M.R. has a history of hypertension and high cholesterol; his father and paternal grandfather have a history of heart attacks. He was diagnosed with transient angina after a chest CT, 12-lead EKG, and lab draw. M.R. was treated in the E.D. according to the chest pain protocol and transferred to the cardiac intermediate unit. The patient has been complaining of feeling short of breath over the last 15 minutes after ambulating in the hall. He reports his pain as a 2/10 in his chest.
Objective – Most recent vital signs: BP 150/86, HR 90, Respirations 24, SpO2 on RA 90%. Slight cyanosis noted around lips, breath sounds clear bilaterally, no extra heart sounds noted, heart rhythm regular, A & O x 4, all pulses 3+.
Analysis – Activity intolerance related to recent chest pain as evidenced by increased respirations, decreased oxygen saturation, lip cyanosis, and feelings of dyspnea.
Plan – Apply oxygen via nasal cannula at 2L, sit patient up in bed, encourage slow and deep breathing, and call provider for further instructions/recommendations.
Implementation – Patient boosted in bed and HOB elevated to 90 degrees, nasal cannula applied with oxygen at 2L, and educated patient about the importance of slow, deep breathing. Provider was called after other interventions were initiated.
Evaluation – After 10 minutes vital signs were: BP 148/85, HR 85, Respirations 16, SPO2 95% on 2L O2. No cyanosis was noted, and patient reported feeling able to breathe “better”. Will continue to monitor.
Example 2:
Subjective – Patient L.W. is a 38 year old female with a penicillin allergy who presented to the ED this morning with severe abdominal pain. L.W. has no significant past medical history, and her mom and maternal aunt both have a history of breast cancer. She had an abdominal pain workup in the ED and was diagnosed with a ruptured appendix. L.W. was taken immediately to surgery for a laparoscopic appendectomy; she just arrived on the med-surg unit after recovering in the PACU. L.W. is complaining of abdominal pain at an 8/10 and feelings of nausea.
Objective – Most recent vital signs: BP 130/80, HR 92, Respirations 16, SpO2 on RA 98%. No cyanosis noted, breath sounds clear bilaterally, no extra heart sounds noted, heart rhythm regular, A & O x 4, all pulses 3+, incision dressing is C/D/I, and all skin appears normal for ethnicity. L.W. is grimacing and guarding her abdomen.
Analysis – Severe pain related to abdominal surgery as evidenced by the patient grimacing, guarding her abdomen, and abdominal pain rating of 8/10.
Plan – Administer pain medication per order (Dilaudid 2mg IV push q 4-6h PRN pain), position patient into a more comfortable position, and reassure patient that the pain will be better soon.
Implementation – 2mg Dilaudid IV push was administered, patient was repositioned and supported with more pillows, and patient was calmly spoken to about how the pain medicine would be helpful.
Evaluation – After 15 minutes vital signs were: BP 126/80, HR 75, Respirations 15, SPO2 98% on RA. L.W. rated abdominal pain at a 2/10 and reports feeling more comfortable. Will continue to monitor and provide pain relief as indicated.
