Chapter 8 Flashcards
SOAPIE
S = Subjective data: Information gathered from what the patient, family, or other source has said or reported
O = Objective data: Information gathered through direct observation by the person performing the assessment; may include a physiological measurement such as blood pressure or a behavioral response such as affect
A = Assessment: The nurse’s interpretation of the subjective and objective data
P = Plan: The actions or treatments to be carried out (may be omitted in daily charting if the plan is clearly explained in the written nursing care plan and no changes are expected)
I = Intervention: Those nursing actions that were actually carried out
E = Evaluation: Evaluation of the problem following nursing intervention (some nursing interventions cannot be evaluated immediately, so this section may be optional)
DAR
D = Data: Information that supports the stated focus or describes pertinent observations about the patient
A = Action: Immediate or future nursing actions that address the focus, and evaluation of the present care plan along with any changes required
R = Response: Description of patient’s responses to any part of the medical or nursing care
APIE
A = Assessment: A complete patient assessment is conducted at the beginning of each shift. Results are documented under this section in the progress notes. Some institutions elect instead to use a daily patient assessment sheet designed to meet specific needs of the unit. Explanation of any deviation from the norm is included in the progress notes.
P = Problem: A problem list, or list of nursing diagnoses, is an important part of the APIE method of charting. The name or number of the problem being addressed is documented in this section.
I = Intervention: Nursing actions are performed, directed at resolution of the problem.
E = Evaluation: Outcomes of the implemented interventions are documented, including an evaluation of patient responses to determine the effectiveness of nursing interventions and the presence or absence of progress toward resolution of a problem.
