26`=

(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.

Problem intervention evaluation

• P—Deficient knowledge regarding surgery related to inexperience.
• I—Explained normal preoperative preparations for surgery. Demonstrated TCDB exercises. Provided booklet on postoperative nursing care.
• E—Demonstrated TCDB exercises correctly. Needs review of postoperative nursing care.

(Data—Action—Response)

D—Stated, “I'm worried about what it will be like after surgery.” Asking frequent questions about surgery. Has had no previous experience with surgery. Wife present and is supportive.A—Explained normal preoperative preparations for surgery. Demonstrated TCDB exercises. Provided booklet on postoperative nursing care.R—Demonstrates TCDB exercises correctly. Needs review of postoperative nursing care. States, “I feel better knowing a little bit of what to expect.”

• Charting by exception
• focuses on documenting deviations from established norms. This approach
• reduces documentation time and highlights trends or changes in a
• patient's condition (Mosby, 2006). It is a shorthand method for
• documenting normal findings and routine care based on clearly defined
• standards of practice and predetermined criteria for nursing assessments
• and interventions. With standards integrated into documentation forms
• such as predefined normal assessment findings or predetermined
• interventions, a nurse then only documents significant findings or
• exceptions to the predefined norms. The nurse writes a progress note
• only when the standardized statement on the form is not met. Assessments
• are standardized on forms so all caregivers evaluate and document
• findings consistently.