9 Tips on How To Make a Good SOAPIE
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.
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there must be AEB in planning and in evaluation.
please send me what are the wrong things in this SOAPIE. thank you.
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LikeIf a rapport was established then the pt. ought to have said something. There was nothing subjective. Need an O2 sat. Im sure theres more but thats what I saw so far.
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LikeYes, that's one. :) Good job.
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