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?



Correct Answer: A

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.




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