Learn how to write a nursing SOAP note using a postoperative pain case. The framework captures what the patient says, vital signs and observations, your nursing diagnosis, and your plan including education and non-drug interventions. The expanded SOAPIER format adds what you did, how the patient responded, and what you changed.
So here the S stands for subjective. So what the patient tells you their words, their feelings or their concerns. Subjective data. The O is objective data, the facts that you can measure. Things like vital signs, lab results and what you observe as the nurse. And then as for assessment your nursing diagnosis based on that subjective and objective data. And then the P is your plan. So what are you going to do about it? Now let me give you a example to help this kind of come together and make more sense. So S subjective would be something like the patient states, I'm worried about controlling the pain after my surgery. And then O for objective might be a heart rate of 98 beats per minute, the patient is restless and they're unable to sleep. And then your assessment could be anxiety related to fear of post operative pain management. And then P for your plan, that could be something like educating the patient on the post operative pain medications, what they're going to be receiving, what times they'll be receiving it, and then some non pharmaceutical pain relief techniques that they could use to help relieve their pain. Now you can expand this to soapy and soapier by adding I for intervention, which is the specific actions that you implemented from your plan, and then E for evaluation, which is the patient's response to it. Something like the patient verbalized their understanding of the pain management plan and the patient was able to fall asleep and then R for revision, which this would be any change to the plan if your interventions didn't work.
