Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is using SOAP format to document a client’s progress note.
What does SOAP stand for?
Subjective, Objective, Assessment, Plan. This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Situation, Observation, Action, Problem is not a documentation method, but a communication tool used in handovers and briefings.
Summary, Outcome, Analysis, Process is not a documentation method, but a framework for writing reflective essays.
Source, Opinion, Accuracy, Purpose is not a documentation method, but a criteria for evaluating information sources.
Subjective, Objective, Assessment, Plan. This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong because Situation, Observation, Action, Problem is not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong because Summary, Outcome, Analysis, Process is not a documentation method, but a framework for writing reflective essays.
Choice D is wrong because Source, Opinion, Accuracy, Purpose is not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.