SOAP Note Example | Nursing SOAP Note

In this video, we are going to go through the different types of nursing notes, specifically soap, Soapy, and SOAPIER nursing notes. We will walk through examples that after this video, you will know exactly what a SOAP note is in nursing school and how to write an awesome one. Now, trust me, you will seriously impress your clinical instructors when it comes time to write your own SOAP note at Clinical. You will know exactly what to write and how to format it. You'll feel a lot more confident in your nursing school clinicals, and you'll also be able to answer any questions that come up about it on your nursing school exams. And of course, I have a free cheat sheet to help you learn things faster in nursing school. So be sure to stay until the end of the video and I will let you know where you can snag that. Now hit that subscribe button and click the notification bell and let's dive in. Okay, so let's start with the fact that soap Snap, Soapy and Soapier Charting are all very straightforward and to the point. So don't worry, they're all very similar. I know there's three of them and it sounds kind of overwhelming, but don't worry, I will break them all down. We'll go through the differences of them, and you'll really understand it after this. Now, you'll also need to check with your clinical facility to see which one is used there. Now, some clinical sites may prefer one over the other, so just be sure to check next time you're at clinical. So first, let's break down exactly what soap, soapier, SOAPY and SOAPIER stand for. Now, SOAP Charting stands for Subjective Objective, Assessment and Plan. Now, SOAPY Charting adds two more onto that, Intervention and Evaluation. And finally, SOAPIER stands for Subjective Objective Assessment, Plan, Intervention, Evaluation, and Revision. Now, don't worry, we will walk through each of these portions of charting, and then depending on what your facility or your nursing program preferences are, you can shorten it to make it work for you. The letters all stand for the same thing. It's just how expansive they want to go. So if you wanted to include more, you would expand to soapier. And if it was more brief, it could be soap. Which type of charting you will use depends on your instructor and the clinical facility, so don't worry about that too much. The important thing is to know what it stands for. And that way, no matter which format you are asked to use, you will know exactly how to use it. All right, so let's dive into what each of these letters stands for. That way, when it Comes time to answer a question on your nursing school exams or when you start writing your clinical notes, you will know exactly how to do it. So when you see the S, think subjective. The subjective portion goes over what the patient is saying or feeling as told by them. So it could be the patient explaining their anxiety about pain control following surgery or if the patient tells you they're feeling dizzy while they are sitting on the edge of their bed. Now these things would be subjective data, subjective points. Now subjective data is something you can't measure, but it's based on how the patient is feeling or their opinion. So your patient saying that they are having trouble sleeping and feeling nauseous because they are thinking about their upcoming surgery, now that is subjective, it cannot be measured, and it's based on what the patient is feeling. Now the O stands for objective data. Now this is the part that states the facts and the values that can be measured by you. Now this would be vital signs, lab results, test results, things that are measurable. So if the patient's heart rate was increased, that would be objective data. Their heart rate is objective because you can actually measure it. Now the A in soap soapy and soapier stands for assessment. This is the area where you put your findings as the nurse and your clinic clinical judgments. So what you are observing or what the patient tells you and what you think is going on or how they are doing based on their subjective and objective data. Now say for example, if the patient expressed anxiety about post op pain, you would say that the patient was experiencing anxiety as evidenced by the patient verbalizing anxiety and is showing increased restlessness and an inability to sleep prior to surgery. Now you could note that this has increased, increasingly worsened as the surgery got closer. Now the pee and soap charting is the plan and this is the part where you get to show off what your plan is to help your patient. Now this would be where you would say you will explain the post operative pain management schedule to your patient, review the post op procedure and reiterate that the patient's feelings are valid and that we're here to help. Now soapy and Soapier charting include the eye for intervention, but SOAP charting does not. So just follow the letters S O A P I E or S O A P I E R. Now under the eye for interventions. That's where you'll write exactly what you did to help your patient. So for example, the pain management schedule was reviewed with the patient and the schedule of events for surgery was reviewed to help the patient feel more comfortable with the post op plan. Now the E stands for evaluation. The evaluation portion is where you evaluate if your interventions actually helped or not. You would say your patient verbalized they felt more comfortable with the post operative pain management plan and that they were able to fall asleep. Or maybe the interventions didn't quite work and something needs to change. Now that would go into the next part, the R. The R stands for reassessing, revision or review and it's not used all the time. But this is where you would look at your evaluation and document any changes that you would make in order to improve the outcome for your patient. So if your patient wasn't able to lower their anxiety level with your initial interventions, you may have to write out the pain management schedule with them to have another reminder or maybe something else that may improve the problem you've identified. Now be sure to check out the clinical charting videos that we have for you inside the Nursing SOS Membership Community where we dive into other types of charting as well, like narrative charting and what abbreviations and acronyms to use and never use and all other things Nursing Charting and remember, there are three ways I can help you more through nursing school. Number one, download this free cheat sheet to help you learn things faster in nursing school and be able to critically think better. It will give you a solid study plan to follow so you can raise your grades without studying for a thousand hours each week. And if you want more help through nursing school, check out our nursing school boxes that we have available for you. They are packed with resources to help you succeed in nursing school. And of course, if you want me to hold your hand throughout your nursing school journey, don't miss out on joining the Nursing SOS Membership Community. It is loaded with step by step nursing lectures to help you understand everything faster for nursing school so you'll be more prepared for your exams. Now. The links to all of those things are in the description box below. And if you liked this video, be sure to hit that like button. Leave a comment below to let me know that you loved it. And of course share it with a friend that might also need help with soapier charting. And of course subscribe and hit that bell so you never miss a video. And click on one of these videos right over here so you can keep rocking nursing school. And as always my friend, go become the nurse that God created only you to be. And I'll catch you next time on the Nursing School Show. Take care. Bye bye.