Flashcards
SOAPIER Documentation
Flashcards do conjunto (10)
- 1SOAPIER DefinitionAn acronym for seven different aspects of charting. For notes on specific patient problems, only the necessary parts needed for completeness are used.
- 2SOAPIER (S)S:
Subjective information is what the patient states or feels; only the patient can provide this information. - 3SOAPIER (O)O:
Objective information is what the nurse can measure or factually describe. - 4SOAPIER (A)A:
Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need. - 5SOAPIER (A)A:
Assessment refers to an analysis or potential diagnosis of the cause of the patient's problem or need. - 6SOAPIER (P)P:
Plan is the general statement of the plan of care to be given or action to be taken. - 7SOAPIER (I)I:
Intervention or implementation is the specific care given or action taken. - 8SOAPIER (E)E:
Evaluation is an appraisal of the response and effectiveness of the plan. - 9SOAPIER (R)R:
Revision includes the changes that may be made to the original plan of care. - 10SOAPE DefinititionThe briefer adaptation of the charting format for the POMR.
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- Fundamentals of Nursing FlashCards sobre SOAPIER Documentation, criado por SherieChristina em 15-05-2015.
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