Development of a Patient Care Plan SOAP Note
Description
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Development of a Patient Care Plan
submit “SOAPE Notes” for the development of a care plan for various patients. SOAPE is an acronym that stands for Subjective, Objective, Assessment, Plan, Evaluation, which are the principal elements of patient care report writing. As an introduction to the concept and process of writing SOAPE notes, take a look at any (or all!) of the following videos.
Instructions
Select each tab below to access and view the videos.
Accessible Interactive Instructions: Use the arrow keys to navigate between tabs. After selecting a tab, use the Tab key to move to the tab content.
Nursing Care Plans Made Easy
Nursing Care Plan Tutorial
Nursing Process OverviewParts of a Care Plan
To summarize and provide a quick reference to the information in the videos, the six principal components of a SOAPE notes are outlined below.Instructions
Click the tabs for key points of each component.Accessible Interactive Instructions: Use the arrow keys to navigate between tabs. After selecting a tab, use the Tab key to move to the tab content.
- Subjective Data
- Objective Data
- Nursing Diagnosis (Assessment)
Planning/Interventions
Evaluation
The chief complaint should be a brief statement, usually a direct quote from the patient, which answers the question, Why are you seeking care? Examples include:
I have heartburn, especially at night.
Ive had a sore throat and a cough for a week.
The patient points to right upper quadrant of abdomen and states, I have pain here.
