"S (subjective data) - chief complaint or other information
the patient or family members tell you.
O (objective data) - factual, measurable data, such as observable
signs and symptoms, vital signs, or test values.
A (assessment data) - conclusions based on subjective and
objective data and formulated as patient problems or nursing
P (plan) - strategy for relieving the patient's problems,
including short- and long-term actions.
I (interventions) - measures you've taken to achieve expected
E (evaluation) - analysis of the effectiveness of your interventions.
R (revision) - changes from the original care plan"
(this information is from page 676 of Portable RN: The All-in-One
Nursing Reference, third edition, published by Lippincott,
Williams & Wilkins, 2007)
These examples of SOAP and SOAPIE charting come from page
677 of the same reference, Portable RN: The All-in-One Nursing
Reference, third edition, published by Lippincott, Williams
& Wilkins, 2007:
"[Nursing diagnosis]#1 Nausea related to anesthetic
S: Patient states, "I feel nauseated."
O: Patient vomited 100mL of clear fluid at 2255.
A: Patient is nauseated.
P: Monitor nausea and give antiemetic as necessary.
I: Patient given Compazine 1mg IV at 2300.
E: Patient states she's no longer nauseated at 2335.
[Nursing diagnosis]#2 Risk for infection related to incision
[notice there is no "S" charted--no subjective data
O: Incision site in front of left ear extending down and around
the ear and into neck--approximately 6" in length--without
dressing. No swelling or bleeding, bluish discoloration below
left ear noted, sutures intact. Jackson-Pratt [JP] drain in
left neck below ear with 20mL bloody drainage. Drain remains
secured in place with suture.
A: No infection at present.
P: Monitor incision sites for redness, drainage, and swelling.
Monitor JP drain output. Teach patient S&S [signs and
symptoms] of infection prior to discharge. Monitor temperature
[Nursing Diagnosis]#3 Delayed surgical recovery
O: Patient oriented x 3 but groggy. Patient attempted to get
OOB [out of bed] at 2245 to ambulate to bathroom but felt
dizzy upon standing. Lungs sound clear bilaterally.
A: Patient is dizzy when getting OOB. Patient needs post-op
education about mobility and coughing and deep-breathing exercises.
P: Allowed patient to use bedpan. Assist in getting OOB in
1 hour by dangling legs on side of bed for a few minutes before
attempting to stand. Monitor blood pressure. Teach patient
how to get out of bed slowly to prevent dizziness and to ask
for assistance. Teach coughing and deep breathing, turning,
use of antiembolism stockings.
I: Allowed patient to lie down in bed after feeling dizzy.
Patient used bedpan and voided 200mL clear, yellow urine at
2245. Assisted in coughing and deep-breathing exercises and
taught about turning, use of antiembolism stockings.
E: Lungs remain clear bilaterally.
[Nursing Diagnosis]#4 Acute pain related to surgical incision.
S: 2245 patient states, "No" when asked if she has
pain. At 2335 patient states, "It hurts."
O: Patient reports incisional pain as 7/10 on scale of 0 to
A: Patient is in pain and needs pain medication.
P: Give pain meds as ordered.
I: Patient given morphine 2mg IV at 2335.
E: Patient states pain as 1/10."