SOAPIER Note Charting Examples

Non-Nursing SOAPIER Note:

(Don't let the words "SOAPIER Notes" or "Issue-Oriented Charting" scare you! The steps of the Nursing Process (reflected in SOAPIER charting) are really something you do every day in multiple scenarios. You are simply going to apply this problem-solving way of thinking and doing to your nursing, and put it in a written form.)

Date/time: 1/10/10, approximately 3pm. Setting: Husband/father returns home, having enjoyed Saturday morning fishing with friends. He walks into the living room and finds his three childrenand chaos. #1. Interrupted family processes related to unexplained chaos as evidenced by crying children, cluttered environment, missing caretaker. S: Bobby states, "I'm hungry!" Jennifer and Megan say, "Me, too." Megan reports, "Bobby hit me!" All report, "We don't know where Mommy is." O: All three children are crying. Toys and clothing litter the floor making it difficult to walk. No blood on children or floor. All children are alert and oriented x 3. Wife is not present; does not respond when her name is called. A: The children are hungry. No one is hurt very badly. The living room is a mess. Location of wife/mother not known. P: Find wife. Enlist children to help pick up room. Feed the children. I: Called wife's name in the back yard. Called her cell phone. Found wife on bed where she had accidentally fallen asleep from exhaustion. Told wife to continue her nap that I (husband) would take care of things for a while. Helped children pick up toys and clothes. Made peanut butter sandwiches, carrot sticks, and apple "smiles." E: The children stopped crying and cooperated with project "Clean-up." They ate the prepared food, said thank you, and went outside to play in the back yard. After her nap, wife reports feeling much more rested and gave me a kiss. R: Develop a strategy with wife to enable her to get more sleep.

Nursing SOAPIER Note #1:

Date: 9/30/09 Setting: Interview took place once again in patients Hogan in Indian Wells. The setting was similar to last week, only this time her husband was not present during the whole interview. He was in and out of the house doing chores. The interview took place around 9:15 a.m. and the patient seemed awake and cheerful.

1. Acute pain in soles of feet related possibly to disease and medications as evidenced by MJ reporting her feet hurt 10/10. S: MJ states that her feet are still hurting when she walks and cleans the house. The pain is a 10/10. She says the pain usually lasts for about 4 hours at a time and often keeps her up at night. She characterizes the pain as burning and aching. She says the pain goes away if she sits and rests for periods at a time. MJ also reports that she has been soaking her feet in warm water every other day and using 2 pills of Tylenol (650mg) for pain. MJ says that this helps, but does not cure the pain. MJ also reports that she has burns between her toes from when she feel asleep next to a fire and didnt notice her feet were burning. She currently puts silver sulfadine on the burns once a day, or when she remembers. This medication was left over from an injury her husband had previously. She is concerned because the burns have been there for the past 3 weeks and do not seem to be healing. O: VS: temp 98.5, RR 14, HR 70. MJs feet did not appear swollen, but she did have burns on her left foot between her 3rd and 4th toes. The burns were open with no drainage. They were both about 1x1 cm long and wide and had white edges. She also had 2 bruises on the top of her right foot which were about 2x2 cm and 1x1 cm in length and width that she reported were from dropping a pan on her foot. MJ was sitting during the interview, but was wearing flip-flops and didnt walk very much. A: MJs foot pain could be due to neuropathy as evident by her reports of burning and aching pain. Her pain could also be from wearing footwear with inadequate arch support. MJ is probably experiencing pain from burns, which may be healing slowly due to some of her medications (prednisone and previous hydrocortisone use). P: Continue to evaluate her pain each week to see if it gets better or worse. Continue to treat pain with Tylenol, rest, stretches, and heat therapy until MJs doctor appointment on 10/15/09. Continue to monitor burn healing. I: Gave MJ Tylenol for when she runs out next week. Performed a focused pain assessment on her feet which got her thinking about non-medicated interventions for her pain. This includes soaking her feet in warm water, resting after being on her feet, and performing some PT exercises her Dr. taught her. E: MJ said that Tylenol was helpful but didnt take away all of the pain. She also stated that soaking her feet helps her pain quite a bit. Rest seems to be the best way to take away her pain.

R: As of now there are no revisions needed. Her doctor appointment is in a few weeks and he will hopefully give her some arch supports or pain medications.

Nursing SOAPIER Note #2:

Date: 10/7/09 Time: 1310-1420 Visit: Second official visit with my assigned family. Roads passable this week. Arrived at patients residence. Patient's son-in-law answered door and showed me into living room where pt. was sitting on couch. Home neat and warm. Patient dressed in warm appropriate traditional clothing. Good hygiene; although, traditional hair bun was not fixed. Patient greeted me and seemed to be happy to see me. Patient's daughter and two granddaughters were also present. Nursing Diagnosis #1: Knowledge deficit related to medication use as evidenced by doubling dosing, wrong time administration, altered mental status, and family sharing of medications. S: The clients family discussed the concern about their mother/grandmothers medication schedule and the fact that she controls all of her medication administration. They stated that sometimes she would forget that she took a dose of medication and then take another dose. She has also been known to share her medications with her children, even though her children do not know what the medications do. Granddaughters report pt. has oncology appointment on Monday, and a "bone and joint" appointment on Tuesday of next week. O: When asked about her medication, pt knew the use of 5 out of the 10 prescribed to her. Her vital signs were stable with RR 16 and HR 68. Although her pain rating was at a consent 8/10, pt did not know that she was allowed to take her hydrocodone/APAP 1 -2 tablets every 4-6 hours. She believed that she could only take 1 tablet every 6 hours. Medication bottles indicate they have been prescribed by 4 different doctors and have been filled at different facilities. A: Patient and family have a vast knowledge deficit related to prescribed medication. Current medication administration is unsafe and ineffective for pain control. No adverse medication symptoms noted or reported. There may be medication changes after Monday and Tuesday's dr. appointments. P: Short-term plan: Review all of the information family receives during pt oncology appointment on Monday and the bone and joint appointment on Tuesday. Compare pt medications for any possible interactions, since medications were prescribed by 4 different doctors, and filled at different facilities. Devise a teaching device (chart) that will simply tell the patient what the medication does, how often she can take it, when she should take it, and side effects. Long-term plan: Continue to assess patient/family medication knowledge. Develop, with the family, a safe administration plan based on clear knowledge of all medications.

I: Engaged in open and respectful communication with daughter regarding her mothers medication use. Spoke to family about patients upcoming doctors appointments. Gave them a few questions to ask the doctor concerning her pain, medicines, and treatments. Reviewed a few medications with patient and her family. Started slow to figure out which learning model works best. Concluded that they are mostly visual learners. E: The two granddaughters, who are the primary caregivers for my patient, were very happy with the idea of me providing them with questions to ask the doctors. Also, I think they really appreciated the idea of me going over the answers or any questions they have regarding their grandmothers conditions. R: Will continue with my plans regarding creating a teaching tool as I now know that a visual tool would be the best to facilitate learning. Next meeting, I will present this teaching tool to my patient and further evaluate the effectiveness of my interventions. Also, I will research any new medications that my patient is placed on after her doctors appointments.