DOCUMENTATION SYSTEM SOAPIE · 2020. 10. 16. · Documentation System/SOAPIE SO A PI E: Su b j e ct...
Transcript of DOCUMENTATION SYSTEM SOAPIE · 2020. 10. 16. · Documentation System/SOAPIE SO A PI E: Su b j e ct...
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DOCUMENTATIONSYSTEMSOAPIE
INSHIRAH QADRI
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Problem-Oriented MedicalRecord (POMR)the data are arranged according to theproblems the client has rather than the courseof the information.
SOAPIE• SOAPIE is a problem oriented medical record
(POMR), where data are arranged according to theproblems the client has.
• It helps in putting the problem list in the front of thechart which alerts care givers to the child needs andmakes it easier to track the status of each problem.
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The POMR compose of:
❑ Database.❑ Problem list.❑ Initial plan.
❑ Progress notes.
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DatabaseConsists of all information known about the clientwhen the client enters the health care agency.
▪ Demographic data▪ Chief complain( subjective & objective data)▪ History present illness such as physiologic
measurements, growth measurements, physicalexamination.
▪ Past history ; medical history surgical historyperinatal history, family history, immunization history,medication history, injuries & allergy .
▪ Nursing actions.
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Problem list• Derived from the database.• Problems are listed in the order in which they are identified,
and continuously updated basis on evaluating the child’shealth.
E.g.:Self care deficit; hygiene ,feeding ,groomingImpaired physical mobilityDM type lConstipation R/T Immobility
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A client’s problem list in the POMR system. Note thatproblems 1B, 1C, and 2 were redefined on the datesindicated and listed subsequently
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Initial plan:
A treatment plan is developed toaddress each problem the patient has
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Progress notes.• Are numbered to correspond to the problems on the
list of problem and may be lettered for the type ofdata.
• are dated, headed, and numbered for specificproblems.
• 20/1/2019 E.g.:8:00 RR 22 B/min, HR 90 B/min, temp 38c°, Bp. 95\60mmHg RN Reem10:30am Passive ROM for R arm and leg RNReem
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Documentation System/SOAPIESOAPIE: Subjective data, Objective data, Assessment, and Planning,interventions, and evaluation.
S (subjective data): information obtained from what theclient says, it describes the client’s perceptions of andexperience with the problem.
• When possible quote the client’s words.• Include only subjective data relevant to the problem.
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SOAPIEO (objective data): information that is measuredor observed.Ex: vital signs, lab results, x-ray reports,medication, &physical assessment, & so on.
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SOAPIEA (assessment): interpretation or conclusion drawn by thenurse about the subjective and objective data.It is a statement of the problem (nursing diagnosis).Examples:Ng Dx: Elimination altered, Constipation R/T ImmobilityShort goal: The child will defecate firm stool withoutdifficulty within 2hrsNg Dx: Comfort altered, abdominal pain R/T surgicalincisionShort goal: The child will verbalize pain intensitydecrease 3 /10 within 1hr
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SOAPIEP (plan): A plan of care designed to resolve the statedproblem.Example:
• Instructed to not scratch skin.• Applied calamine lotion to back and arms twice daily.
I (intervention): An intervention to a particular problem E.g.: Assess pain(OLD CART),check V/S…
E (evaluation): The response to the intervention(reassessment). E.g.: Reassess pain, recheck V/S…
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THANK YOU
References
Hockenberry,M . & Wilson, D. (17 Wong's Essentials of
Pediatric Nursing . 10 th ed, St Louis; The Mosb
Kozier, B., Erb. G., Berman, A., Snyder, S. (2011) Fundamentals
of Nursing Concepts, Process, and Practice (9th ed.) New
Jersey. Pearson Education International