1 SOAP Charting

Objectives 2 At the conclusion of this activity, the learner will able to: 1. Document client interaction in a SOAP format

Materials needed 3 Client Pen/Pencil Paper

SOAP Charting- Definition 4 S- Subjective “ I have fallen down the stairs up to the house two times in the last three months” O- Objective There are no handrails on steps, steps become icy in the winter. Patient is elderly with poor vision- steps are hard to distinguish A- Assessment Potential for injury related to decreased home management skills P- Plan Speak with friends, family, neighbors, service organizations to: put handrails up, scoop steps in winter, and paint bright yellow strip on edge of each stair. Show client how to salt own stairs as needed.

Documenting 6 SOAP charting for visit S - “I am having nausea in the morning and I don’t know what to do about it” O - Client shifts in seat, appears uncomfortable. Has lost one pound this week. A - Knowledge deficit related to morning sickness. P - Offer suggestions to decrease nausea. For example eat a few soda crackers before getting out of bed in the morning. Wendy Wells, RN 10:00AM 5/18/xx

7 SOAP Charting