S.O.A.P.
Format
Recording Skills: The Basis for
Data Collection, Organization,
Assessment Skills, and Treatment
Plans
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Types of Patient Records
Traditional chart
Problem-oriented medical record (POMR)
Computer documentation
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Traditional Chart
Also called block chart or source-oriented
record
Divided into distinct areas or blocks
Emphasis placed on specific information
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Traditional Chart (Cont’d)
Typical blocks include:
Admission sheet
Physician's order sheet
Progress notes
History and physical examination data
Medication sheet
Respiratory care sheet
Nurses’ admission information
Nursing care plans
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Problem-Oriented Medical Record
(POMR)
1. Systematically gather clinical data
2. Formulate an assessment
3. Develop an appropriate treatment plan
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SOAP—
Most Common POMR
S: Subjective information
O: Objective information
A: Assessment (cause of subjective
and objective data)
P: Plan (treatment selection)
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SOAP
S: Subjective information presented by the
patient. For example:
“I coughed hard all night long.”
“My chest feels very tight.”
“I feel very short of breath.”
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SOAP (Cont’d)
O: Objective information that can be measured,
factually described, or obtained from other
professional reports or test results. Includes
the following:
Heart rate
Respiratory rate
Blood pressure
Temperature
Breath sounds
Cough effort
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SOAP (Cont’d)
A: Professional conclusion about the cause of
the subjective and objective data. For
example:
The assessment of bronchospasm can be
concluded from wheezes.
Or, acute ventilatory failure with moderate
hypoxemia can be inferred from the following
ABGs:
• pH: 7.18
• PaCO2: 80 mm Hg
• HCO3: 29 mEq/L
• PaO2: 54 mm Hg
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SOAP (Cont’d)
P: Plan is the therapeutic procedure(s) selected
to remedy the cause identified in the
assessment. For example:
An assessment of bronchial smooth muscle
constriction justifies the administration of a
bronchodilator
The assessment of acute ventilatory failure
justifies mechanical ventilation
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SOAPIER
Extended SOAP model with the added “IER”
I: Implementation—the actual administration
of the specific therapy plan
E: Evaluation—collection of measurable data
regarding the effectiveness of the plan
R: Revision—refers to any changes that may
be made to the original plan in response to
the evaluation
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SOAP Case Example
A 26-year-old man arrived in the emergency
room with a severe asthmatic episode. On
observation, his arms were fixed to the bed
rails, he was using his accessory muscles of
inspiration, and he was using pursed-lip
breathing. The patient stated that “it feels like
someone is standing on my chest. I just can’t
seem to take a deep breath.”
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SOAP Case Example (Cont’d)
His heart rate was 111 beats per minute and
his blood pressure was 170/110. His
respiratory rate was 28 and shallow.
Hyperresonant notes were produced on
percussion. Auscultation revealed expiratory
wheezing and rhonchi bilaterally. His chest x-
ray revealed a severely depressed
diaphragm and alveolar hyperinflation.
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SOAP Case Example (Cont’d)
His peak expiratory flow was 165 L/min. Even
though his cough effort was weak, he produced a
large amount of thick white secretions. His arterial
blood gases showed a pH of 7.27, a PaCO2 of 62,
and an HCO3 of 25, and a PaO2 of 49 (on room air)
(see Figure 10-1).
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SOAP Case Example
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General Information
Age: 26
Sex: male
Admitting diagnosis: asthma
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Admitting Diagnosis: Asthma.
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SUBJECTIVE
“It feels like someone is standing on my chest.”
“I just can’t seem to take a deep breath.”
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OBJECTIVE
RR 28
HR 111
BP 170/110
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OBJECTIVE
Use of accessory muscles
Pursed-lip breathing
Hyperresonant
Expiratory wheezing and rhonchi (bilateral)
X-ray exam: Severely depressed diaphragm
PEFR: 165
Weak cough
Large amount of thick white secretions
pH 7.27, PaCO2 62, HCO3 25, PaO2 49
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OBJECTIVE ASSESSMENT
Use of accessory muscles
Respiratory distress
Pursed-lip breathing
Hyperresonant
Exp. wheezing Bronchospasm
Rhonchi Lg. airway sec.
X-ray film: Severely depressed diaphragm
PEFR: 165
Weak cough Poor ability to mobilize
thick secretions
Lg. amt thick and white sec.
pH 7.27, PaCO2 62, HCO3 25, PaO2 49 Acute ventilatory failure
and severe hypoxemia
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ASSESSMENT Plan
Respiratory distress
Bronchospasm Bronchodilator Tx
Lg airway secretions
Bronchial hygiene Tx
Poor ability to mobilize
thick secretions
Acute ventilatory failure and Mechanical vent. Tx
severe hypoxemia Oxygen Tx
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Figure 10-1. Completed predesigned SOAP form.
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Figure 10-1:
Abbreviated Form
S: “It feels like someone is standing on my chest. I
can’t take a deep breath.”
O: Use of acc. mus. of insp.; HR 111, BP 170/110, RR
28 and shallow, pursed-lip; hyperresonance; exp.
whz; diaph. and hyperinfl.; PEFR 165; wk. cough;
lg. amt. thick/white sec.; pH 7.27, PaCO2 62, HCO3
25, PaO2 49
A: Bronchospasm; hyperinflation; poor ability to mob.
tk. sec.; acute vent. fail. with severe hypox.
P: Bronchodilator Tx/pro.; CPT and PD/pro.,
mucolytic/pro., mech. vent/pro.; ABG 30 min
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Figure 10-2 A, Respiratory care protocol guide.
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Figure 10-2 B, Respiratory care protocol guide.
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