SOAP - Microsoft

SOAP - Microsoft

SOAP, ADPIE & ISBAR HEALTHCARE MNEMONICS Anne M. Simpson ASN, BS, RN-BC About Me Began in Healthcare 2006 Graduated Nursing school 2008 Board Certified in Cardiovascular Nursing

Practicing in a Cardiovascular ICU In school to earn Master of Science Degree in Nursing SOAP NOT JUST FOR THE SHOWER SOAP Assessment S Subjective data

O Objective data Facts vital signs, results from tests, lab work A Assessment

What the patient tells you Physical exam P Plan Interventions This Photo by Unknown Author is licensed under CC BY-NC-SA SOAP Provider Example

S Patient c/o sore throat, watery eyes, headache x 3days O VS WNLs, temp 98.6, Lab work WNLs, A Neurologically intact, clear drainage from Nares, palate erythema P - Ibuprophen for pain, zyrtec for rhinitis

SOAP Nursing Example S Patient c/o sore throat, watery eyes, headache x 3days O VS WNLs, temp 98.6, Lab work WNLs, A Patient at risks for impaired swallowing

P Position patient upright at 90-degrees for meals ADPIE WHAT KIND OF PIE? ADPIE THE NURSING PROCESS A - Assessment D - Diagnosis

P - Plan I - Interventions E - Evaluate ISBAR A COOL PLACE FOR COFFEE ISBAR - COMMUNICATION

I - Identify S Situation B Background

A Assessment R - Recommendation This Photo by Unknown Author is licensed under CC BY-NC-ND ISBAR Example I Hi Dr. Bock this is Anne from CVICU calling about Mr. Smith in room 2330

S The patient is complaining of pain in his left upper chest at his pacemaker site B Mr. Smith had a permanent pacemaker inserted this morning and has allergies to tylenol A Patient c/o 7/10 pain, PM site is C/D/I

R I would like an order for 2mg of Morphine PRN for pain q2h. Questions?

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