339 SOAP Charting Definition SOAP charting is a type of charting that emphasizes the problem-solving approach to patient care. The SOAP format includes documentation of the subjective and objective assessment findings, plan of care, and health care provider and nurse’s orders, as follows: S: Subjective information obtained from a patient regarding the patient’s or family’s description of the problem or symptoms O: Objective information based on the OHN’s or health care provider’s observations of a patient, a physical examination, and diagnostic or laboratory tests A: Assessment of the OHN’s or health care provider’s analysis of a patient’s problem based on the subjective and objective data gathered P: Plan of care to be provided to solve the problem Example Dan is a maintenance mechanic. In working today on the air-conditioning system in the base- ment of the cafeteria, he cut his left hand on a piece of metal. Dan went to occupational health services to get a bandage. 0900 10/31/2002 Problem: Laceration to left hand (Always include date and time of visit.) S: “I cut my hand on a piece of metal.” Employee lacerated left hand today while working on the air-conditioning system in the cafeteria. Employee complains of bleeding to left hand and denies discomfort. Employee states that he had a tetanus shot 2 years ago. O: One-inch superficial laceration to left hand with small amount of bleeding. No debris or metal visible in the wound. A: Superficial laceration to left hand. P: Left hand cleansed with antibacterial soap and rinsed with warm water wound dressed with a dry, clean bandage. Employee instructed to keep laceration covered and clean and to return to health services if redness, swelling, or pain from laceration occurs or if fever develops.
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