Format of Progress Notes (DAR)
Format of Progress Notes (DAR) ( 5 Questions)
A nurse is using the SOAP format to document the progress notes of a client who has hypertension.
The nurse needs to select all that apply when writing the plan of care for this client.
Which of the following are appropriate components of the plan in the SOAP format?
Monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.
Educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.
Assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.
Evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.
Identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.
These are appropriate components of the plan in the SOAP format. SOAP stands for Subjective, Objective, Assessment, Plan and it is a form of written documentation many healthcare professions use to record a patient or client interaction.
• A is correct because monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.
• B is correct because educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.
• D is correct because evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.
• C is wrong because assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.
• E is wrong because identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.
Normal ranges for blood pressure are <120/80 mmHg for normal, 120-129/<80 mmHg for elevated, 130-139/80-89 mmHg for stage 1 hypertension, and ≥140/≥90 mmHg for stage 2 hypertension. Normal ranges for pulse rate are 60-100 beats per minute for adults.