DOCUMENTATIONSYSTEMSOAPIE

INSHIRAH QADRI

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.

The POMR compose of:

❑ Database.❑ Problem list.❑ Initial plan.

❑ Progress notes.

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.

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

A client’s problem list in the POMR system. Note thatproblems 1B, 1C, and 2 were redefined on the datesindicated and listed subsequently

Initial plan:

A treatment plan is developed toaddress each problem the patient has

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

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.

SOAPIEO (objective data): information that is measuredor observed.Ex: vital signs, lab results, x-ray reports,medication, &physical assessment, & so on.

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

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…

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