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SOAPIER Documentation

SherieChristina Fundamentals of Nursing English 10 cards 3,716 views

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  1. 1SOAPIER DefinitionAn acronym for seven different aspects of charting. For notes on specific patient problems, only the necessary parts needed for completeness are used.
  2. 2SOAPIER (S)S:
    Subjective information is what the patient states or feels; only the patient can provide this information.
  3. 3SOAPIER (O)O:
    Objective information is what the nurse can measure or factually describe.
  4. 4SOAPIER (A)A:
    Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need.
  5. 5SOAPIER (A)A:
    Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need.
  6. 6SOAPIER (P)P:
    Plan is the general statement of the plan of care to be given or action to be taken.
  7. 7SOAPIER (I)I:
    Intervention or implementation is the specific care given or action taken.
  8. 8SOAPIER (E)E:
    Evaluation is an appraisal of the response and effectiveness of the plan.
  9. 9SOAPIER (R)R:
    Revision includes the changes that may be made to the original plan of care.
  10. 10SOAPE DefinititionThe briefer adaptation of the charting format for the POMR.

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Fundamentals of Nursing Flashcards on SOAPIER Documentation, created by SherieChristina on 15/05/2015.
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