SOAP, ADPIE & ISBAR Healthcare Mnemonics

Anne M. Simpson ASN, BS, RN-BC About Me Began in Healthcare 2006 Graduated Nursing school 2008 Board Certified in Cardiovascular Nursing Practicing in a Cardiovascular ICU In school to earn Master of Science Degree in Nursing

SOAP Not just for the shower

SOAP Assessment S – Subjective data O – Objective data A – Assessment What the patient tells you O – Objective data Facts – vital signs, results from tests, lab work A – Assessment Physical exam P – Plan Interventions This Photo by Unknown Author is licensed under CC BY-NC-SA

SOAP Provider Example S – Patient c/o sore throat, watery eyes, headache x 3days O – VS WNLs, temp 98.6, Lab work WNLs, A – Neurologically intact, clear drainage from Nares, palate erythema P - Ibuprophen for pain, zyrtec for rhinitis

SOAP Nursing Example S – Patient c/o sore throat, watery eyes, headache x 3days O – VS WNLs, temp 98.6, Lab work WNLs, A – Patient at risks for impaired swallowing P – Position patient upright at 90-degrees for meals

ADPIE What Kind of pie?

ADPIE – The Nursing Process A - Assessment D - Diagnosis P - Plan I - Interventions E - Evaluate

ISBAR A cool place for coffee

ISBAR - Communication I - Identify S – Situation B – Background A – Assessment R - Recommendation This Photo by Unknown Author is licensed under CC BY-NC-ND

ISBAR Example I – Hi Dr. Bock this is Anne from CVICU calling about Mr. Smith in room 2330 S – The patient is complaining of pain in his left upper chest at his pacemaker site B – Mr. Smith had a permanent pacemaker inserted this morning and has allergies to tylenol A – Patient c/o 7/10 pain, PM site is C/D/I R – I would like an order for 2mg of Morphine PRN for pain q2h.

Questions?