Charting Methods and Formats in Nursing

Healthcare professionals, including nurses, have the enormous responsibility of gathering accurate patient information consistent with the principle of patient-centered care. Moreover, clinical staff have the obligation of incorporating patient information with scientific evidence and professional expertise to deliver high-quality and safe patient care. Standard operating procedures and charts are essential to guide nurses and other clinical staff in ensuring accurate and efficient patient care, including precise assessment to avoid misdiagnosis of patient problems. Therefore, it is imperative to describe the SOAP and PIE charting in nursing.

SOAP Charting

Documentation is a crucial component in healthcare for accountability and reference purposes. The process should be well-defined and organized for standardization and ease of reference. Consequently, the SOAP acronym representing subjective, objective, assessment, and planning is a popular documentation strategy that ensures efficient and structured documentation in healthcare practice (Podder et al., 2020). The method is helpful to guide clinical staff in having focused execution of patient evaluation while highlighting specific aspects.

Comprehensive assessment of a patient for definitive diagnosis and treatment is the product of the accurate utilization of the SOAP format. Consequently, the format can record critical aspects of patient information that guided clinical decision-making. Furthermore, the multidisciplinary care team can have effective communication concerning all aspects of patient care based on the SOAP charting. Therefore, SOAP is an effective protocol that guided clinical reasoning among healthcare professionals for high-quality patient care. The format structure follows the order of Subjective information, Objective data, Assessment, and Planning.

Subjective component

The section is essential to gather the patient’s experiences, personal feelings, or opinions of the patient’s significant others regarding the patient’s healthcare status or the reason that made the patient seek medical attention. Moreover, the subjective component provides a foundation to conduct subsequent orders or procedures. The comprehensive execution of the subjective element involves assessing the patient’s chief complaint, history of presenting illness, history taking, review of systems, and the presence of current medications or allergies.

Objective Component

The clinician gathers the objective patient data through comprehensive physical examinations, vital signs observation, and diagnostic tests such as laboratory or imaging investigations. Moreover, findings by other clinical staff constitute objective data.

Assessment

The integration of subjective and objective data to generate patient diagnosis is the assessment component of the SOAP format. The patient cc and interaction of body systems are essential to state the accurate patient diagnosis and other plausible problems often referred to as the differential diagnosis. The differential diagnosis must be in the order of highest to lowest probability.

Plan

The plan involves the statement of the necessity of additional investigations and senior review or consultations. Moreover, the plan component serves as a communication tool between the multidisciplinary team members regarding the patient’s therapy.

Proposed Improvement of the SOAP Charting

Standard operating procedures may need continuous improvement to ensure high-quality patient care. For this reason, the SOAP format may need rearrangement to assume the order APSO for ease of access of information on ongoing care (Podder et al., 2020). The APSO order is beneficial to physicians to refine the efficiency and accuracy of structuring patient information for chronic disease management while ensuring effective communication of patient information.

Communication of Patient Information Using SOAP Charting

Patient’s name: John Smith. DOB: 08-10-1951. Sex: Male

Clinician: Dr. Jerry Jones

Subjective

Chief Complain

The patient complains of left arm pain. Additionally, the patient complains of leg weakness that increases with going up steps with bilateral leg pains.

History of Presenting Complains

A 70-year-old male patient presenting with pains in the left arm, legs, and left leg weakness that increases with going up steps. The patient’s leg pain is aching, worsening at night. Moreover, the pain is better when he elevates his legs.

Objective

Vital signs

BP- 165/85mmHg, PR- 60bpm, RR- 16 breaths per minute, Temperature-98.5 degrees Fahrenheit, SPO2-97%, pain -5 out of 10 scale, height- 182cm, Weight- 165kg.

Physical Examination findings

The patient has peripheral edema of both ankles and inflammation on both legs.

Imaging investigations

The patient has leg fractures following X-ray studies.

Assessment

The patient’s diagnosis is hypertension with bilateral leg and ankles edema, heart diseases, and diabetes.

Plan

The patient should elevate his legs for one hour four times a day. Moreover, the patient to take 25mg Hydrochlorothiazide tablet once daily in the morning. The patient should don support stocking until the next appointment at two weeks.

PIE Charting

The problem-focused charting method constitutes the acronym PIE that stands for Problem, Intervention, and Evaluation. The process assumes a definite problem-oriented structure with the SOAP format. Moreover, the PIE charting ensures satisfactory quality documentation in terms of comprehensiveness and conciseness to record patient’s pertinent information (Almasi et al., 2018). The simplicity of structure ensures efficiency in collecting and recording patient’s information as opposed to the time-consuming SOAP format. Structurally, the problem component denotes the patient’s diagnosis, such as ineffective breathing patterns. Clinical interventions are essential to alleviate the patient’s problem, while the evaluation component establishes the impact of interventions to improve the patient’s clinical status.

Patient Scenario

Problem

A 46-year-old female patient is admitted to the emergency department with a chief complaint of excessive vaginal bleeding for the last 12 hours. Additionally, she has used over nine fully soaked gynaecological pads since the onset of bleeding. The patient reports general body weakness, and on examination, she appears lethargic and has pallor demonstrated in the palms of hands and the conjunctiva of the eyes. Vital signs observation reveals that the patient has a blood pressure of 88/54mmHG, a pulse rate of 111bpm, a temperature of 38.6degree Celsius, a Respiratory Rate of 25breaths per minute, and saturating at 86% room air. Therefore, the patient’s life-threatening problem is deficient fluid volume related to abnormal uterine bleeding as evidenced by being lethargic, BP of 88/54mmHg, and pulse rate of 11bpm.

Interventions

Prompt treatment is essential to prevent the complication of the patient’s clinical state or even death. Therefore, interventions should aim at restoring adequate fluid volume status within the next 6 hours, with the indicators being blood pressure of over 100/60mmHg, Pulse rate of lower than 100bpm, and urine output at the rate of 25mls per hour, and resolved lethargy. Therefore, the RN secured large-bore intravenous access then administered Hartman’s solution one liter in the first 20 minutes, one liter in 30 minutes, and slow infusion at 3mls per minute after the first hour. The patient received intravenous Tranexamic acid 1g STAT as ordered. Additionally, it is imperative to periodically monitor the patient’s vital signs while highlighting blood pressure, urine output, and pulse rate.

Evaluation

Healthcare professionals have to ensure high-quality patient care through consistent assessment of patient’s responses to therapeutic interventions. Therefore, the patient with low fluid volume demands close monitoring to detect complications such as shock with acute kidney injury. After six hours, general observation reveals that the patient is less lethargic, evidenced by prompt response to questions and alertness. Assessment of vital signs establishes an improvement in the blood pressure level to 103/59mmHg. The pulse rate is still elevated at 96bpm but lower than the initial observation. Furthermore, the patient has a urine output at the rate of an estimated 28mls per hour with the cessation of profuse per vaginal bleeding. Nonetheless, the pallor demands administration of blood products such as whole blood.

References

Almasi, S., Cheraghi, F., Dehghani, M., Ehsani, S., Khalili, A., & Alimohammadi, N. (2018). Effects of problem, intervention, evaluation (PIE) training on the quality of nursing documentation among students of Hamadan University of Medical Sciences, Hamadan, Iran. Strides in Development of Medical Education, 15(1). Web.

Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP notes. In StatPearls. StatPearls Publishing. Web.