(Subjective—Objective—Assessment—Plan)S—“I'm worried about what it will be like after surgery.”O—Asking frequent questions about surgery. Has had no previous experience with surgery. Wife present and supportive.A—Deficient knowledge regarding surgery related to inexperience. Patient also expressing anxiety.P—Explain routine preoperative preparation. Demonstrate and explain rationale for turning, coughing, and deep breathing (TCDB) exercises. Provide explanation and teaching booklet on postoperative nursing care.
An I and E are sometimes added (i.e., SOAPIE) in some institutions. The I stands for intervention, and the E represents evaluation. The logic for SOAPIE notes is similar to that of the nursing process. You collect data about a patient's problems, draw conclusions, and develop a plan of care. The nurse numbers each SOAP note and titles it according to the problem on the list.