SOAP ADPIE ISBAR HEALTHCARE MNEMONICS Anne M Simpson

SOAP, ADPIE & ISBAR HEALTHCARE MNEMONICS

Anne M. Simpson ASN, BS, RN-BC About Me • • • Began in Healthcare 2006 Graduated Nursing school 2008 Board Certified in Cardiovascular Nursing Practicing in a Cardiovascular ICU In school to earn Master of Science Degree in Nursing

SOAP NOT JUST FOR THE SHOWER

SOAP Assessment • S – Subjective data • • O – Objective data • • Facts – vital signs, results from tests, lab work A – Assessment • • What the patient tells you Physical exam P – Plan • Interventions This Photo by Unknown Author is licensed under CC BY-NC-SA

SOAP Provider Example • S – Patient c/o sore throat, watery eyes, headache x 3 days • O – VS WNLs, temp 98. 6, Lab work WNLs, • A – Neurologically intact, clear drainage from Nares, palate erythema • P - Ibuprophen for pain, zyrtec for rhinitis

SOAP Nursing Example • S – Patient c/o sore throat, watery eyes, headache x 3 days • O – VS WNLs, temp 98. 6, Lab work WNLs, • A – Patient at risks for impaired swallowing • P – Position patient upright at 90 -degrees for meals

ADPIE WHAT KIND OF PIE?

ADPIE – THE NURSING PROCESS • A - Assessment • D - Diagnosis • P - Plan • I - Interventions • E - Evaluate

ISBAR A COOL PLACE FOR COFFEE

ISBAR - COMMUNICATION • I - Identify • S – Situation • B – Background • A – Assessment • R - Recommendation This Photo by Unknown Author is licensed under CC BY-NC-ND

ISBAR Example • I – Hi Dr. Bock this is Anne from CVICU calling about Mr. Smith in room 2330 • S – The patient is complaining of pain in his left upper chest at his pacemaker site • B – Mr. Smith had a permanent pacemaker inserted this morning and has allergies to • A – Patient c/o 7/10 pain, PM site is C/D/I • R – I would like an order for 2 mg of Morphine PRN for pain q 2 h. tylenol

Questions?