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SOAP and FDAR Charting Revised For Students

Charting

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Dexter Pait
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32 views

SOAP and FDAR Charting Revised For Students

Charting

Uploaded by

Dexter Pait
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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SOAP and FDAR Charting

NURSES’ PROGRESS NOTES


Assessment

Types:
1. Initial Assessment
2. Problem Focused
3. Emergency Assessment
4. Time- lapsed Reassessment
Under Assessment:

Steps:
1. Data Collection
Types of Data:
A. Subjective Data/ Covert Data/ Symptoms
B. Objective Data/ Overt Data/ Signs
Sources of Data:
A. Primary
B. Secondary
Methods of Data Collection:
Observation (includes…)
Interview
Examination
2. Organize Data
3. Validate Data
4. Document/ Record/ Communicate Data
Diagnosing

Nursing Diagnosis:
Types of Nursing Diagnoses:
1. Actual Diagnosis:
2. Potential Nursing Diagnosis/ High Risk: (no s/s yet but risk
factors are present)
3. Possible Nursing Diagnosis:
4. Wellness Diagnosis:
Components:
1. Problem Statement/ Diagnostic Label: (altered, impaired,
decreased, ineffective)
2. Etiology: (…related to)
3. Defining Characteristics:
*Formulation and Variations
Planning
Processes:
1. Setting Priorities: establishing order for health problems to be
prioritized
Guide:
A.
B.
C.
Ex. Activity Intolerance Vs Decreased Cardiac Output
Activity Intolerance Vs Risk for Injury
Activity Intolerance Vs Acute Pain
2. Establishing Goals: expected outcomes
Goals:
Objectives:
(Criteria: SMART)
Ex. Nsg. Dx.: Hyperthermia related to decreased circulating
blood volume
After 30-45 minutes of independent and dependent nursing
interventions, the patient’s core temperature will decrease from
38.5 Deg C to 37 Deg C or even lower but within normal range.
3. Selecting Nursing Interventions/ Strategies: refers to specific
nursing actions to a nursing diagnosis, that a nurse carries out to
achieve objectives and goals
Criteria:
A.
B.
C.
D.
E.
Categories:
A. Diagnostic:
B. Therapeutics:
C. Educational:
4. Developing a NURSING CARE PLAN: written guide that organizes
information about client’s care
Importance:
provides direction for individualized care
provides continuity of care
provides complete documentation
serves as guide for assigning staff
Format:
Assessme Explanatio Goals & Nursing Rational Evaluation
nt n of the Objectives Interventio es
Px : ns
Implementation

Skills that must be evident:


A. Cognitive Skills
B. Interpersonal Skills
C. Technical Skills
Evaluation

- Client’s progress
- Effectiveness of nursing intervention

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