Scribd
Upload
5 views2 pages

Short SOAPIE

The document outlines a Nursing SOAPIE Note format, which includes sections for patient information, subjective and objective data, analysis, planning, interventions, and evaluation. Each section requires specific details regarding the patient's condition, nursing diagnoses, and care plans. The goal is to create a comprehensive and patient-centered nursing care record.

Uploaded by

waljawabreh32
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
5 views2 pages

Short SOAPIE

The document outlines a Nursing SOAPIE Note format, which includes sections for patient information, subjective and objective data, analysis, planning, interventions, and evaluation. Each section requires specific details regarding the patient's condition, nursing diagnoses, and care plans. The goal is to create a comprehensive and patient-centered nursing care record.

Uploaded by

waljawabreh32
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Nursing SOAPIE Note (10%)

Student name________________________________________University no:______________


Instructor’s Name:_________________________
Patient Name
Date of birth: age: gender:
Chief complain:
Medical diagnosis:

Patient Information (2)


Subjective (3) : (Document what the patient personally reports, including perceived pain, symptoms (e.g.,
numbness, tingling),. Current complaints, current appetite, intake problems, current status of defecation and urination,
any knowledge deficit regarding the current case or medication or intake etc, sleeping pattern currently, Psychological
status (fears, anxiety, …etc))

Objectives ( 3) : (Record observable clinical findings from the nurse’s assessment, including what is seen, heard,
felt, and measured. This includes vital signs, physical exam findings, lab results, and imaging studies, depending on the
setting.)

Analysis (Diagnosis) ( 2): (Analyze the collected subjective and objective data to identify key nursing diagnoses. Use
NANDA-approved terminology, and include the problem definition, etiology (cause), and defining characteristics.)
Plan ( 2) : (Develop a patient-centered plan of care based on the nursing diagnosis. This include choosing goal
and an outcome and plan repositioning, pain management, oxygen therapy, emotional support, or other nursing
interventions. The plan should be tailored to the patient's specific needs.)

Interventions ( 2): List planned nursing actions to address the diagnosis and achieve outcomes. Include (List
independent, dependent, and collaborative nursing actions with rationale.)

Evaluation ( 1): Assess the patient’s progress towards the outcomes. Determine if the plan should be continued, adjusted,
or terminated based on the patient’s response.

You might also like