SOAPIER and ISOBAR Flashcards
1
Q
S- Subjective
A
- Subjective data consist of information obtained from what the person says. It describes the person’s perceptions of and experience with the problem
2
Q
O – Objective
A
– Objective data consist of information that is measured or observed by use of the senses (e.g. vital signs, laboratory and x- ray results).
3
Q
A – Assessment
A
– The interpretation or conclusions drawn about the subjective and objective data.
4
Q
P – Plan
A
- The plan of care designed to resolve the stated problem
5
Q
I- Intervention/Implementation
A
- Specific interventions that have actually been performed by the
caregiver.
6
Q
E – Evaluation
A
– Includes responses to nursing interventions and medical
treatments. This is primarily reassessment data.
7
Q
R – Revision
A
– Reflects care plan modifications suggested by the evaluation.
8
Q
I- Identify
A
- Myself, designation, date and time
- Person the situation was escalated to
9
Q
S- Situation
A
- Clinical deterioration
- Patient meeting create for escalation
- Post procedure
10
Q
O- Observation
A
- Recent vital signs
- Clinical Assessment
11
Q
A- Assessment
A
- Actions taken
- Review request
12
Q
R- Recommendation
A
- Requested/recommended intervention
- Instructions of the medical officer conveyed verbally
- Confirmation that instruction of medical officer were followed
