Nurses notes or SOAPIE, SOAP, SOAPIERS, SOI, are like integrated within a nurse’s DNA but some of student nurses are still “learning” the right way on how to make a good SOAPIE. This post will give you some tips on how to do so.

1. Assess, assess, assess.

Say that fast three times. Keep in mind that assessment is the base of a SOAPIE. To have a good assessment (and not to stick with pinkish palpebral conjunctiva and CRT ^^), be aware of the “medical diagnosis” of your patient.

For example, you have a patient who was diagnosed of congestive heart failure or heart failure. If its your first time to encounter the disease try to read before hand (that’s why you have to bring a handy-dandy handbook about diseases). Try to recall as much as possible what could be the manifestations of a patient with heart disease. Start first with the fact that it affects the heart then narrow your assessment down.

Let say you know that heart failure can be left-sided and right-sided. For right-sided HF, I know that it there is systemic edema, so I would assess for edema. I also know that there are changes in the heart’s pumping ability, thus I would assess for regularity of the pulses bilaterally. As for the left-sided HF, I know that there is pulmonary congestion thus I would assess for DOB, breath sounds (your favorite assessment), and etc.

If so you would know the signs and symptoms of a patient with CHF and thus you would assess for them (central cyanosis, jugular vein distention, edema, DOB, rhythm of pulses and etc).

Assessment is like a line from a song “it takes a lot of getting used to“. But don’t be discouraged, that’s why you are a nursing “student”, you are still in the peak of learning. Make it a habit that you do an appropriate and close to detailed assessment.

2. Know what your doing

Also make it a point that you know what to assess before your interact with your patient, instead of going back to the patient’s room q5 mins just to ask whether he voided or whether the palpebral conjunctiva is pink. Don’t be a disturbance to a patient who is recuperating.

3. NANDA out

If its your first time to write a SOAPIE, its okay to use the NANDA, but if your a 4th year and you would be graduating in the next (let’s say) 2 weeks shame on you. (For those who doesn’t know what NANDA is, it is the best friend and most overused book by a nursing student).

So going back, if its your first semester for your hospital exposure, go ahead use your NANDA and remember the cues, the related factors, the interventions and what would you want the patient achieve.

Don’t be NANDA dependent, (nandamit).

4. Stop Using Acute Pain…

Its quite a good idea that some instructors would disallow the nursing diagnosis of acute pain. “My head aches” (acute pain), “I feel like there’s an elephant in my chest” (acute pain), “my tummy feels like twisting” (acute pain) and yes there are a lot of instances where acute pain be used that is why if NANDA would write down specifically all the related factors it would be as thick as the MS book of Joyce Black.

5. …choose a better nursing diagnosis!

At the back portion of the NANDA, there’s a list of medical diagnoses and their possible nursing diagnoses and their related factors, make sure to browse that. Make sure that you have an appropriate nursing diagnosis for your patient. Here are some key points:

• Your nursing diagnosis should be “strongly supported by your assessment cues”
• It should be patient centered (as most of the time)
• and it should follow a format like the “diagnosis-related factor-cues”

Some nursing diagnoses can stand alone even without related factors like Hyperthermia. Although these type of diagnoses are limited to SOAPIEs and not on care plans.

6. Planning should be SMART and PtC

Planning is also what we know as goal setting. This is where you ask “what would I want my patient to achieve?” Goals or plans should be SMART:

• Specific and Measurable. End your planning with AEB and then cues that you would assess to confirm whether you have achieved your goal. Example: “…the patient will establish airway patency as evidenced by (AEB) effective respirations, respiratory rate within normal range and demonstration of deep breathing exercises and effective coughing exercises”.
• Attainable and Realistic. A case with severe pneumonia: “After 1 hour of NI the patient will establish normal respiration AEB…”. This is quite unattainable (go figure).
• Time Bound. Make sure that the time you’ve put in your planning is enough to achieve your desired outcomes.

Be patient centered as much as possible. The patient is at the center of planning because he/she is the chief decision maker of what treatment plans he/she would allow. You patient is not the significant other. Be cautious of also using the phrase “verbalize understanding of…” to pediatric patients. Also, don’t restrict your planning or goals on what’s written on NANDA.

7. Interventions

You can start with established rapport, then assess the general condition, monitor the vital signs and then…you can start writing the real interventions in your SOAPIE.

Make sure that all assessment-like interventions should be within the first few lines of your

Note that the assessment-like interventions are at the first few lines

interventions. Assessment-like interventions are those interventions wherein you would say that you assessed for this and that like monitored hydration status, auscultated bowel sounds, assessed neuro vital signs.

The rest of your interventions should be next. Don’t ever, ever forget to shift to past tense. Put dependent nursing interventions last like administered medications.

Also remember some “templates” for interventions like “Above IVF consumed hooked #2 D5LRS 1L…”, “hooked O2 inhalation regulated at 2-3 LPM via nasal canula” and especially “seen on rounds by Dr. Xyz with orders made and carried out:…”

And lastly, always make sure to add in your interventions the explanation of the disease of the client. A good student nurse knows the importance and impact of health education to the prognosis of the patient.

8. Horray! Evaluation.

Finally, we have arrived at the evaluation. Was your planning or goal met? partially met? or not met? How would you assess whether they were met? Simple. If you have made a good planning it should have ended with AEB and then their corresponding cues. These cues are your parameter whether you have met your goal.

As for the example above was your able to manifest effective respiration and rate within normal range? deep breathing and coughing exercises?

9. And to Top it all up…

I hope you have enjoyed and learned a lot by reading this post. If you liked this please share it on Facebook! You can click on the floating Facebook logo at the side. Also you can subscribe to our posts!

And lastly, here is an example SOAPIE, with all the things you have learned above can you comment what’s wrong with this SOAPIE?

• S > (none) O> Received pt sitting in bed conscious and coherent, with IVF of #7 D5W 1L infusing well on the right metacarpal vein regulated 30 gtts/min at 300 cc level, without signs of phlebitis or infiltrations. O2 inhalation therapy via NC regulated @ 2LPM pt appears fatigued and weak, pt is acyanotic, without pallor, without edema, with pink conjunctiva, moist mucous membranes, capillary refill less than 3 seconds, poor skin turgor, pt has cough with lung fields clear upon auscultation, with chest pain provoked with activity, pt’s heart rate is irregular and bradycardic, with ecchymosis on L forearm, vital signs taken as follows: BP 90/50 48 22cpm 36.7
• A > Decreased cardiac output R/T altered heart rate
• P> After 4-5 hours of NI the patient will be able to identify health interventions that will decrease cardiac workload of the heart
• I >
  • Established rapport
  • Monitored and recorded VS q1
  • Provided AM care
  • Positioned pt in fowler’s bed rest to allow easy respiratory function
  • Reinforced low sodium and low fat diet
  • Instructed pt to limit oral fluid intake
  • Arranged and straightened linens
  • Provided privacy, comfort and safety measures
  • Provided adequate rest periods
  • Assisted pt’s SO with pt’s ADLs
  • Instructed pt to avoid strenuous activities that may stimulate Valsava maneuver
  • Due available meds given as ordered
  • Seen on rounds by Dr. N with orders given and carried out as follows:
    • Atrophine sulfate ½ amp administered SIVP

E> Goal met AEB pt was able to identify health interventions that would allow decrease in cardiac work load.

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