A Guide to SOAPIE Charting [+ Examples]

A Guide to SOAPIE Charting [+ Examples]

One of the most important aspects of working as a nurse is documentation. New nurses are often surprised by the amount of time that they spend behind a computer throughout their workday, charting and writing important nursing notes. Although your charted assessments will likely be documented using a charting program such as EPIC, Cerner, Allscripts, or MEDITECH, you will frequently run into situations when you need to type out a nursing note. Having a template for these notes can make it much easier to relay all of the important information to clearly communicate what’s happening in a given situation.
Nurse Taking Notes
Sophia M.

  ·  

September 7, 2022

Table of Contents

The SOAPIE charting method is a commonly used template for nursing notes that can be very helpful for any nurse. This article will break down what SOAPIE notes are and how to use them. 

What is SOAPIE Charting?

SOAPIE stands for subjective, objective, assessment, plan, intervention, and evaluation. Subjective information includes anything related to what the patient has told you. Objective information is measurable and consists of any of your personal observations. The assessment is the nurse’s interpretation of this information and conclusions regarding the patient’s condition. Intervention includes any actions that were taken to support the patient. Evaluation describes the result of any interventions. Later on in this article, I’ll share more information about how to write SOAPIE notes along with some examples. 

This format for note taking is also oftenused by doctors in their documentation. When caring for patients, nurses are required to chart patient assessments and document any other important information. Typically, charting consists of entering patient information into an online chart by clicking through a spreadsheet and entering in information such as the patient’s pain rating on a scale of 1-10, when the patient last had a bowel movement, etc. This type of charting is often done in a “box checking” type of format, however, you will run into situations  when you have to write a free text note to document information about a patient. In these situations, it is important to lay all of the information out in a clear and concise manner, so breaking down the information clearly through a template like SOAPIE is super helpful. 

How to Write SOAPIE Notes? [+ SOAPIE Examples]

When are SOAPIE notes used?

Although most charting as a nurse will not require you to use a format such as SOAPIE, you will run into situations when you have to write a free text note and having knowledge on SOAPIE charting is incredibly helpful. Every hospital has different requirements and every nurse tends to do things a little differently, so your preference for writing free text notes will vary. 

SOAPIE Charting Steps

The steps for writing SOAPIE notes are pretty straight forward and it will only take a little practice to become an expert on SOAPIE charting. Below, I’ve broken down the steps it takes to document a clear and concise nursing note by using the SOAPIE charting format. 

  1. Subjective information

Start your SOAPIE note by listing any subjective information about the patient. The subjective information includes anything regarding the patient’s experience that the patient or family has told you. Subjective information can also include your own observations about the patient, such as their appearance or behavior. Common examples of subjective information that you may want to document include the patient’s stated pain level, their report of feeling short of breath, or the patient stating they have felt abnormally tired for the last few days. 

  1. Objective data

Next, you’ll want to share any relevant objective information. Objective data includes any patient information that can be measured or observed by the five senses. Examples of objective data include the patient’s blood pressure, respiratory rate, oxygen saturation, body temperature, heart rate, or skin color. Accurately documenting objective data is important since it can give other care providers a clearer picture of what is going on with a patient and how stable they are. Objective data is also important because when there is a dramatic change it can be clearly seen by care providers to help determine the proper course of treatment. 

  1. Nursing assessment

The next step in your SOAPIE note is to complete and document a nursing assessment. Depending on the situation, you may be able to complete a focused assessment or you may want to complete a full head-to-toe assessment. A focused assessment involves assessing the patient based on what their complaints are. For example, if your patient is short of breath, you may listen to their lung sounds but not bother with a neuro assessment. Again, this decision will be based on your hospital’s policy and your own nursing judgement. Use what you find during the assessment to document any conclusions you have about the patient’s condition. 

  1. Plan

For the next section of your SOAPIE note, you’ll need to document the treatment plan for the patient. Discuss any new orders that the physician placed that are relevant to the given situation such as new medications, blood levels that will be checked, or other team members who need to be notified. 

  1. Intervention

This is where you will document any actions that were taken by you or anyone else on the patient’s care team. Interventions can include a wide variety of nursing actions such as administering medications, drawing blood, putting the patient on oxygen, or performing a dressing change. 

  1. Evaluation

Lastly, you’ll want to evaluate the results of any of the actions that were taken for the patient. Document whether they were helpful or if the patient’s condition changed at all. If your patient was transferred to another unit, you’ll need to document that their care was transferred to another nurse who will continue to monitor them. Many nurses end their notes with the phrase “will continue to monitor”.

SOAPIE Example #1 

Some nurses prefer to type out a nursing note when their patients are discharged. In the SOAPIE format, it may look something like this:

“The patient stated that they understood all discharge instructions and felt comfortable returning home. They are alert and oriented, vital signs are stable. This RN agrees they are ready to be discharged home based on a stable assessment. A family member will come pick them up. No further interventions needed. Patient safely walked off of the unit.” 

SOAPIE Example #2 

Some other situations when you may use SOAPIE formatting to type out a nursing note may be if your patient’s condition has declined and they’ve been transferred to a more intense unit, such as the ICU. In this situation, your nursing note may look something like this:

“Patient stated ‘I feel short of breath’ when the RN came in to check on them. Vitals signs showed BP 110/75 HR 100 RR 22 SPO2 89. Patient appeared fatigued and pale. This RN contacted the charge RN, rapid response nurse, and primary care physician. Oxygen was given to the patient via nasal cannula. SPO2 increased to 95, respiratory rate slowed to 18. The patient was transferred off of the med-surg unit and sent to the ICU due to unstable condition. Report given to ICU nurse who will continue to monitor the patient’s condition.” 

To help further breakdown this example, here is how each segment of this note fits into the SOAPIE formatting: 

  • Subjective: Patient stated ‘I feel short of breath’
  • Objective: Vitals signs showed BP 110/75 HR 100 RR 22 SPO2 89.
  • Assessment: Patient appeared fatigued and pale.
  • Plan: This RN contacted the charge RN, rapid response nurse, and primary care physician.
  • Intervention: Oxygen given to the patient via nasal cannula.
  • Evaluation: SPO2 increased to 95, respiratory rate slowed to 18. The patient was transferred off of the med-surg unit and sent to the ICU due to unstable condition. Report given to ICU nurse who will continue to monitor the patient’s condition.

Over time, it will get easier to understand when a free text nursing note is necessary and your hospital will likely have their own policies regarding when and how to document free text notes. As a new nurse, you’ll want to check with your coworkers or supervisor if you think a nursing note is warranted in a given situation. If you’re ever unsure about whether or not you need to document extra information in the form of a free text note, it is always best to play it safe and add a note. Documentation is important and it is much better to document more than necessary than to document less than necessary, since it will help other care providers track the progression of a patient and understand their situation. 

SOAPIE vs. SBAR

Another common form of nursing communication that can easily be confused with the SOAPIE note is the SBAR. SBAR stands for situation, background, assessment, and recommendations. This concept is more often used during verbal communication, while the SOAPIE format is more common for written communication. As a newer nurse, you’ll want to get used to the SBAR format of communication as well since you will likely use it when giving reports to other nurses, such as during shift changes or when transferring one of your patients to a new unit. SBAR is also an effective way to communicate with doctors when you need to make a call regarding a patient’s condition. This form of communication can help you lay out all the necessary information so that the doctor can quickly get a clinical picture of what is happening to a specific patient. 

Final Thoughts

Clear communication and documentation are some of the most important aspects of being a nurse and providing high-quality patient care. SOAPIE notes are one of many methods for nurses to write out their nursing notes, but they provide a useful framework to ensure that all necessary information is provided. If you’re a newer nurse, I definitely recommend spending some time getting used to this method of note taking prior to starting out at your first nursing job.

Sophia

Sophia M.

My name is Sophia. I am a Registered Nurse with experience working as a floor nurse on a Renal Care Unit and Hematology/Oncology Unit.

Further Reading

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