You may have heard the adage in nursing school or from a co-worker: As a nurse, “if you didn’t chart it, it didn’t happen!” Charting takes up a large portion of your shift, especially if you are doing it correctly. While time-consuming, good charting is essential to providing top-notch patient care. Not only does charting provide nurses and doctors caring for a patient on future shifts an accurate picture of what happened on previous shifts, but it also becomes a permanent part of the patient’s medical record. It can even be used for legal purposes.
Some organizations have certain requirements for how charting must occur. Most hospitals have gone to a computerized documentation system, but you may occasionally come across an institution that still does things with pen and paper. Regardless, writing a good note at the end of your shift is essential for every patient.
There are several different ways to write a nursing note, but this article will focus on one of the most popular and how it is written: the SOAPI note. This article will break the SOAPI note down so you can decide if it’s a format that will work for you. As always, be sure to check with your organization to determine how they want their notes written.
The term “SOAPI” is actually an abbreviation of the parts of the note. These are Subjective, Objective, Assessment, Plan, and Interventions.
Subjective refers to things the patient can tell you and often includes pain level and feelings or concerns. It can also refer to things a patient’s family members tell you.
Objective refers to hard data you collect regarding the patient. This can include vital signs, laboratory results, observable signs and symptoms, and your physical assessment findings.
Assessment refers to your overall interpretation of the subjective and assessment. Is the patient improved since admission? Are there new issues that you are observing that need to be addressed? All of these things belong in the assessment.
Plan refers to the patient’s plan of care. How is the medical team addressing the patient’s health problems? Are there upcoming tests or blood draws? Is the patient on medications to treat a problem that you are monitoring response to? These are examples that fall under the plan.
Interventions refer to the things we are doing for the patient. Examples of intervention can include treatments and medications and education provided to the patient on your shift.
Below is an example of a SOAPI note:
Mr. Smith is an 88-year-old male with a diagnosis of congestive heart failure. The patient is alert and oriented x 1 but pleasantly confused. He complained of shortness of breath on this shift and stated the 2 liters of oxygen made him feel better. He verbally denied pain and his nonverbal pain score was 0. His daughter visited today and advised that he was trying to climb out of bed to go to the bathroom because of his confusion. She stated he “forgot he was in the hospital.”
Today, the patient’s vital signs were as follows: BP 162/82, Pulse 64 and regular, Respirations 20 per minute, and pulse ox 98% on 2L Oxygen via nasal cannula. His lungs are diminished with scattered crackles. Bowel sounds are active, and the patient had a bowel movement x 2 today, both soft. Incontinent of urine and wearing a diaper. Skin intact at this time. Skin color is pale. 2+ non-pitting edema noted in bilateral calves and ankles. BNP was greater than 20,000 today.
The patient’s status is improving, and he is less short of breath than in previous days. He continues with edema. Currently, the patient is at risk for falls due to confusion and will need fall precautions enforced.
Initiate fall precautions with a bed alarm/body alarm. Continue with Lasix for diuresis. Awaiting cardiology consult tomorrow. Pt had an echocardiogram today, and the results are pending.
Assessed patient and reconciled medications. Spoke with daughter, pt’s power of attorney, to provide update and education on patient’s condition. Laboratory obtained morning labs without a problem, and vascular therapy placed a new 18g peripheral IV as the previous one was due for a change. Pt took all morning meds without a problem. Reoriented patient and provided opportunities for toileting and for making needs known every 1-2 hours today to lessen the risk of fall.”
With a good quality nursing note, such as a SOAPI note, nurses can make it crystal clear exactly what is going on with a patient’s care. Nursing notes are a crucial part of the patient’s medical record and provide all the information future caregivers will need to provide continuous care for patients in the healthcare setting. And they are also the perfect way to wrap up your shift with confidence and ease.