Conceptual Framework

Ensuring that level II nursing students competency

in SOAPIE charting shows sufficient practical experience to

develop the full range of skills they need for effective

practice has become a focus in conducting this study.

The hospital related learning experience is an

important learning factoring in doing the SOAPIE charting.

In the research paradigm, the study focuses on doing the

charting in the level II nursing students, If the have meet

the competency by the opportunity to utilize the theory and

skills they have learned in the classroom discussion and

skills laboratory and imply it in doing the SOAPIE charting

and it will perceived by their clinical instructor.

The related learning experience (RLE) duties in the

hospital will serve as a tool to enhance more the

knowledge, develop the skills, and improve in formulating

SOAPIE charting skills of the nursing students.

Definition of terms:

SOAPIE charting -is based on a problem or nursing diagnosis

list. Each diagnosis has its own number that never changes.

When a SOAP entry is made, it is preceded by the problem or

diagnosis number and/or name to which it refers.

Following diagnosis identification, information related to

the diagnosis is charted in the following manner:

S (subjective). Anything the patient says; also may include

statements made by family members.

O (objective). Observed data; avoid stating opinions: “Just

the facts.”

A (analysis) (also known as “assessment”). This is the

recorder’s chance to state what he or she “thinks” about what

he or she has seen and heard. This is usually done in the

form of a diagnosis (nurses use nursing diagnoses).

P (planning). Includes nursing actions implemented or to be

implemented. Therapy, teaching, and plans for further

assessment are included regarding the diagnosis in A

(analysis). The plan states who will implement and when

implementation is to take place. (It is important to remember

that the reason many things don’t go “according to plan” is

that there never was a specific plan.)

I (intervention). Documents implementation if not covered in

Plan.

E (evaluation). Documents the effects of the Plan (and

intervention if category is used) on the Analysis

(diagnosis). It may be entered at a different time from the

initial SOAP entry.

Competency -Physical, mental, financial, or legal power to

perform: ability, capability, capacity, competence, faculty,

might