Lecture 9

• SOAP Notes:

  • s: subjective - what patient complains of
  • o: objective - measurable observations
  • a: assessment - professional opinion
  • p: plan - what healthcare professional will do to manage patient outcomes, include expected outcome
• Five steps to patient care plan: continuous

  • assessment
  • systematic collection of data
  • nursing diagnosis
  • treat patient's response to a disease (not disease itself)
  • label
  • etiology
  • signs and symptoms
  • planning
  • plan of action
  • identify expected patient outcome
  • implementation
  • explains why each action should assist in reaching each goal
  • evaluation
• Four components of patient outcome:

  • specific behaviour that shows patient reached goal
  • criteria for measuring behaviour
  • condition under which behaviour should occur
  • timeframe for when behaviour should occur
• Types of intervention:

  • independent - within your scope of practice
  • collaborative - in consultation with other healthcare members outside your scope of practice
• Six components of evaluation:

  • reassessing the patient
  • comparing findings from the outcome
  • determine patient's progress / outcome achievement
  • writing evaluation statements
  • revising care plan including: diagnosis, outcome, intervention
  • documenting evaluation