O Tujuh langkah Varney dalam SOAP

O SubjektiI (Varney langkah 1)

4 Pendokumentasian hasil pengumpulan data klien melalui anamnesis
4 erhubungan dengan masalah dari sudut pandang klien (ekspresi mengenai
kekhawatiran dan keluhannya)
4 Pada orang yang bisu, di belakang data diberi tanda '0 atau 'X
O ObjektiI (Varney langkah 1)
4 Pendokumentasian hasil pemeriksaan Iisik klien, hasil pemeriksaan
laboratorium/pemeriksaan diagnostik lain dan inIormasi dari keluarga atau orang
lain
O O Assessment (varney angkah 2, 3, 4)
4 Pendokumentasian hasil analisis dan interpretasi (kesimpulan) data subjektiI dan
objektiI
iagnosis
iagnosa/masalah potensial
Antisipasi diagnosa/masalah potensial dan tindakan segera
O Planning (Varney langkah 5, 6, 7)
4 Pendokumentasian rencana , tindakan (I) dan evaluasi (E), meliputi: asuhan
mandiri, kolaborasi, tes diagnostik/laboratorium, konseling dan Iollow up
O CATATAN PERKEMANGAN PASEN
O Ada beberapa bentuk Iormat dokumentasi yang dapat digunakan bidan untuk
mengidentiIikasi dan mengatasi masalah klien.
O Jenis -jenis Catatan Perkembangan
O SOAPIER
O SubjektiI, ObjektiI, Assessment, Planning, Implementasi, Evaluasi, Reassessment
O SOAPIE
O SubjektiI, ObjektiI, Assessment, Planning, Implementasi, Evaluasi
O SOAPIE
O SubjektiI, ObjektiI, Assessment, Planning, Implementasi, Evaluasi. okumentasi
O SOAP
O SubjektiI, ObjektiI, Assessment, Planning
O AR (ata , Action, Respon)
O SOAPIER
O ormat SOAPIER lebih tepat digunakan apabila rencana pasien ada yang akan dirubah
dan proses evaluasi mulai dilakukan .
O SubjektiI
4 ata dari klien yang diperoleh dari anamnese atau allo anamnese
4 erhubungan dengan masalah dari sudut pandang klien (ekspresi mengenai
kekhawatiran dan keluhannya)
4 Pada orang yang bisu, di belakang data diberi tanda '0 atau 'X
O O ObjektiI
4 Pendokumentasian hasil pemeriksaan Iisik klien, pemeriksaan
laboratorium/pemeriksaan diagnostik lain, catatan medik dan inIormasi dari
keluarga atau orang lain
O Assessment
4 Pendokumentasian hasil analisis dan interpretasi data subjektiI dan objektiI
(kesimpulan)
iagnosis/masalah
iagnosa/masalah potensial
Antisipasi diagnosa/masalah potensial dan tindakan segera
O O Planning
4 Rencana asuhan yang akan dilakukan berdasarkan hasil analisis dan interpretasi
data
O Implementasi
4 Pelaksanaan tindakan sesuai rencana yang etlah disusun
O Evaluasi
4 Menilai hasil pelaksanaan tindakan
O Reassessment
4 Melakukan pengumpulan data kembali, jika hasil pelaksanaan tindakan tidak
sesuai dengan yang diharapkan
O O S : Subjective Pernyataan atau keluhan pasien
O O : Objective ata yang diobservasi
O A : Analisis Kesimpulan berdasarkan data objektiI dan subjektiI
O P : Planning Apa yang dilakukan terhadap masalah
O I : Implementation agaimana dilakukan
O E : Evaluation Respons pasen terhadap tindakan keperawatan
O R : Revised Apakah rencana akan dirubah
O SOAPIE
O SubjektiI
4 ata dari klien yang diperoleh dari anamnese atau allo anamnese
4 erhubungan dengan masalah dari sudut pandang klien (ekspresi mengenai
kekhawatiran dan keluhannya)
4 Pada orang yang bisu, di belakang data diberi tanda '0 atau 'X
O ObjektiI
4 Pendokumentasian hasil pemeriksaan Iisik klien, pemeriksaan
laboratorium/pemeriksaan diagnostik lain, catatan medik dan inIormasi dari
keluarga atau orang lain
O Assessment
4 Pendokumentasian hasil analisis dan interpretasi data subjektiI dan objektiI
(kesimpulan)
iagnosis/masalah
iagnosa/masalah potensial
Antisipasi diagnosa/masalah potensial dan tindakan segera
O O Planning
4 Rencana asuhan yang akan dilakukan berdasarkan hasil analisis dan interpretasi
data
O Implementasi
4 Pelaksanaan tindakan sesuai rencana yang etlah disusun
O Evaluasi
4 Menilai hasil pelaksanaan tindakan
O SOAPIE
O SubjektiI
4 ata dari klien yang diperoleh dari anamnese atau allo anamnese
4 erhubungan dengan masalah dari sudut pandang klien (ekspresi mengenai
kekhawatiran dan keluhannya)
4 Pada orang yang bisu, di belakang data diberi tanda '0 atau 'X
O ObjektiI
4 Pendokumentasian hasil pemeriksaan Iisik klien, pemeriksaan
laboratorium/pemeriksaan diagnostik lain, catatan medik dan inIormasi dari
keluarga atau orang lain
O Assessment
4 Pendokumentasian hasil analisis dan interpretasi data subjektiI dan objektiI
(kesimpulan)
iagnosis/masalah
iagnosa/masalah potensial
Antisipasi diagnosa/masalah potensial dan tindakan segera
O O Planning
4 Rencana asuhan yang akan dilakukan berdasarkan hasil analisis dan interpretasi
data
O Implementasi
4 Pelaksanaan tindakan sesuai rencana yang etlah disusun
O Evaluasi
4 Menilai hasil pelaksanaan tindakan
O okumentasi
4 Tindakan untuk mendokumentasikan seluruh langkah yang sudah dilakukan
O SOAP ormat SOAP umumnya digunakan untuk pengkajian awal pasen.
O SubjektiI
4 Pendokumentasian hasil pengumpulan data klien melalui anamnesis
4 erhubungan dengan masalah dari sudut pandang klien (ekspresi mengenai
kekhawatiran dan keluhannya)
4 Pada orang yang bisu, di belakang data diberi tanda '0 atau 'X
O ObjektiI
4 Pendokumentasian hasil pemeriksaan Iisik klien, hasil pemeriksaan
laboratorium/pemeriksaan diag
4 nostik lain dan inIormasi dari keluarga atau orang lain
O O Assessment
4 Pendokumentasian hasil analisis dan interpretasi (kesimpulan) data subjektiI dan
objektiI
iagnosis/masalah
iagnosa/masalah potensial
Antisipasi diagnosa/masalah potensial/tindakan segera
O Planning
4 Pendokumentasian tindakan (I) dan evaluasi (E), meliputi: asuhan mandiri,
kolaborasi, tes diagnostik/laboratorium, konseling dan Iollow up
O ata Action Respon (AR)
O ormat dokumentasi . A. R membantu perawat untuk mengatur pemikirannya dan
memberikan struktur yang dapat meningkatkan pemecahan masalah yang kreatiI.
Komunikasi yang terstruktur akan mempermudah konsistensi penyelesaian masalah di
antara tim kesehatan.
O O : ata.
O ata objektiI dan subjektiI yang mendukung masalah
O A : Action.
O Tindakan yang segera harus dilakukan untuk mengatasi masalah
O R : Respons.
O Respons pas i en terhadap tindakan perawat sekaligus melihat tindakan yang telah
dilakukan berhasil/tidak
O ALUR PIKIR IAN PENCATATAN AN ASUHAN KEIANAN PROSES
MANAJEMEN KEIANAN PENOKUMENTASIAN ASUHAN KEIANAN 7
LANGKAH VARNEY 5 LANGKAH (KOMPETENSI IAN) SOAP NOTES ATA ATA
SUJEKTI OJEKTI IAGNOSIS/MASALAH ASSESMENT / IAGNOSIS
O ANALISIS AN INTERPRETASI
O IAGNOSIS
O ANTISIPASI IAGNOSIS /MASALAH POTENSIAL
O TINAKAN SEGERA
ANTISIPASI IAGNOSIS/MASALAH POTENSIAL KEUTUHAN SEGERA UNTUK
KONSULTASI, KOLAORASI
O PLANNING:
O KONSUL
O TES IAGNOSTIK / LAORATORIUM
O RUJUKAN
O PENIIKAN / KONSELING
O OLLOW UP
PLANNING
O PLANNING (OKUMENTASI IMPLEMENTASI):
O ASUHAN MANIRI
O KOLAORASI
O TES IAGNOSTIK / LA
O KONSELING
O OLLOW UP
IMPLEMENTASI IMPLEMENTASI EVALUASI EVALUASI

Subjective components
This describes the patient's current condition in narrative Iorm. The history or state oI
experienced symptoms are recorded in the patient's own words. It will include all pertinent and
negative symptoms under review oI body systems. Pertinent medical history, surgical history,
Iamily history, and social history, along with current medications and allergies, are also
recorded. A SAMPLE history is one method oI obtaining this inIormation Irom a patient.
II this is the Iirst time a physician is seeing a patient, the physician will take a history oI present
illness, or HPI. To structure this portion oI the note, some providers use another mnemonic,
"OL CARTS"
|1|
:
nset
ocation
uration
haracter (sharp, dull, etc)
Alleviating/Aggravating Iactors
Radiation
Temporal pattern (every morning, all day, etc)
Symptoms associated
A variant mnemonic used Ior this purpose is OPQRST.
edit] -ective component
The 4-0.9;0 component includes:
O Vital signs
O indings Irom physical examinations, such as posture, bruising, and abnormalities
O Results Irom laboratory
O Measurements, such as age and weight oI the patient.
edit] Assessment
Is a quick summary oI the patient with main symptoms/diagnosis including a diIIerential
diagnosis, a list oI other possible diagnoses usually in order oI most likely to least likely. When
used in a Problem Oriented Medical Record, relevant problem numbers or headings are included
as subheadings in the assessment.
edit] Plan
This is what the health care provider will do to treat the patient's concerns. This should address
each item oI the diIIerential diagnosis. A note oI what was discussed or advised with the patient
as well as timings Ior Iurther review or Iollow-up may also be included.
OIten the Assessment and Plan sections are grouped together.
edit] An example
A very rough example Iollows Ior a patient being reviewed Iollowing an appendectomy. This
example resembles a surgical SOAP note; medical notes tend to be more detailed, especially in
the subjective and objective sections.

Surgery Service, r. Jones
S: No Chest Pain or Shortness oI reath. "eeling better today." Patient reports Ilatus.
O: AIebrile, P 84, R 16, P 130/82. No acute distress.

Neck no JV, Lungs clear

Cor RRR

Abd owel sounds present, mild RLQ tenderness, less than yesterday. Wounds look clean.

Ext without edema
A:
Patient is a 37 year old man on post-operative day 2 Ior laparoscopic appendectomy, recently
passed Ilatus.
P:
Recovering well. Advance diet. Continue to monitor labs. Prepare Ior discharge home
tomorrow morning.

Note that the plan itselI includes various components:
iagnostic component - continue to monitor labs
Therapeutic component - advance diet
Patient education component - that is progressing well
isposition component - discharge to home in the morning

SOAP Note

How to Write a SOAP Note:

The acronym SOAP stands for SUBJECTVE, OBJECTVE, ASSESSMENT, and PLAN.
Medical documentation of patient complaint(s) and treatment must be consistent,
concise, and comprehensive. Many medical offices use the SOAP note format to
standardize medical evaluation entries made in clinical records. The four parts of a
SOAP note are outlined below.

1. SUBJECTIVE The initial portion of the SOAP note format consists of subjective
observations. These are symptoms verbally given to medical assistants by the patient or
by a significant other (family or friend). These subjective observations include the
patient's descriptions of pain or discomfort, the presence of nausea or dizziness, and a
multitude of other descriptions of dysfunction, discomfort, or illness.

. BJECTIVE The next part of the format is the objective observation. These
objective observations include symptoms that medical assistants can actually see, hear,
touch, feel, or smell. ncluded in objective observations are measurements such as
temperature, pulse, respiration, skin color, swelling, and the results of tests.

. SSESSMENT Assessment follows the objective observations. Assessment is the
diagnosis of the patient's condition. n some cases the diagnosis may be clear, such as
a contusion. However, an assessment may not be clear and could include several
diagnosis possibilities.

. !N The last part of the SOAP note is the plan. The plan may include laboratory
and/or radiological tests ordered for the patient, medications ordered, treatments
performed (e.g., minor surgery procedure), patient referrals (sending patient to a
specialist), patient disposition (e.g., home care, bed rest, shortterm, longterm
disability, days excused from work, admission to hospital), patient directions, and follow
up directions for the patient.

See S! Note exampIe!


on't misunderstand a progress note vs. a SOAP note! As the name implies, a progress
note sums up the progress that has been made in the patient's care since the last note.
SOAP stands for subjective, objective, assessment, and plan. The SOAP note is a brief
report in the patient's chart, done at the day of the appointment when the patient is
seen. t is different from the comprehensive progress note the doctor writes in the
physical diagnosis.

The instructions below should give you a general idea of what information to include
and where. Many of the particulars of your notes will be different for each medical
specialty, so be sure to get feedback from your medical office manager and coworkers
about your notes as early as possible, and adjust your style accordingly.

The SOAP note should briefly express the following:
(1) ate and purpost of the visit. The patient's symptoms and complaints.
() The current physical exam. What is the patient's height, weight, temperature, pulse,
blood pressure, visual acuity, etc.?
() New lab data and results of studies, reports, assessments.
() The current formulation and plan for the patient.

The S! Note:
#emember, the SOAP note is not supposed to be as detailed as a progress report.
Complete sentences are not necessary and abbreviations are appropriate. However,
avoid them until you have a handle on how the abbreviations are used they differ for
each specialty, and are consistent within the medical office where you work.

The length of the note will differ for each specialty as well. Generally, surgical notes are
short and medical notes are long. #emember that the medical assistant student's note
will usually wind up being more detailed than those of the more advanced staff.
Students have less clinical judgment and experience, so they often give a more
thorough report of what they observed

Writing notes is one oI the basic activities that medical students, residents, and physicians
perIorm. Whether it is a detailed pediatric SOAP note or a brieI surgery SOAP note, this is how
we communicate with each other, now and Ior Iuture reIerence. Someone may need to read your
note months or even years Irom now, so you want to make sure your note is written well.

The basic Iormat Ior a note is the SOAP note. SOAP stands Ior:

S - Subjective: any inIormation you receive Irom the patient (history oI present illness, past
medical history, etc)

- Objective: any data, whether in the Iorm oI a physical Iinding during your exam, or lab
results
A - Assessment: diagnoses derived Irom the history and objective data
P - Plan: what you intend to do about the diagnoses Irom your assessment
Pretty simple, right? However, ay 1 on your Iirst rotation comes around, and you're asked to
write a note. You write down "SOAP" but... then what?

Well, iI it is the Iirst time you are seeing a patient, you should write a Iull history and physical
(H&P). The H&P should include the history oI present illness, past medical history, past surgical
history, allergies to meds, current meds, relevant Iamily history (e.g. "Mother and Sister had
breast cancer"), and social history (tobacco history in pack years, alcohol, drugs, etc). or HPI, a
helpIul mnemonic is OL CHARTS:


- Onset: when the problem began
- Location: what area oI the body is aIIected
- uration: how long has it been hurting, is the pain continuous or intermittent
- Character: words to describe the problem (dull, sharp, burning, stabbing, throbbing,
itching, etc)
A - Aggravating / Alleviating actors
R - Radiation
T - Temporal: is there any pattern to the pain, such as always aIter meals
S - Associated Symptoms
It is also a good idea to ask about previous episodes oI a similar pain, or any relevant Iamily
history.

Anyway, back to the SOAP note. Assuming you are Iamiliar with the patient, the SOAP note
details what has occurred since you last saw them, typically the previous day. You want to note
any changes in their condition or treatment. II nothing has changed, you can write "id well ON
(overnight). Tolerating Iood and medications. NA (no acute distress)" or something along those
lines. The objective portion should be their latest vital signs, as well as their "ins & outs" such as
IV Iluids, UOP (urine output), Ms (bowel movements). The objective portion also includes any
new lab or study results. The assessment is generally a restatement oI what the patient's ongoing
diagnosis has been (e.g. "This is a 37 year old Iemale, PO (post-op day)# 3 aIter a lap chole
(laparascopic cholecystectomy)"). The plan describes what you want to do Ior the patient next. In
the hospital, it's a good idea to run through all the major systems in your head and try to think
about what is going on Ior each one. Here is a simple list: Airway/reathing, CNS, CV,
Endocrine, luids, Heme, I, Renal (UOP), Social. epending on the rotation you are on, other
systems may be more relevant. II nothing comes to mind Ior a system, there is usually no need to
mention it unless your residents or attending speciIically want you to.

That's pretty much it. AIter writing several oI these notes, and seeing the other notes in a patient's
chart, one starts to develop their own style oI writing them, so don't be too concerned about
sticking to one particular Iormat as long as you Iind one that suites how you think while covering
all the pertinent inIormation.
or more basic inIormation on how to ask certain histories or perIorm Iocused parts oI the
physical exam, I recommend Bates Guide to Physical Examination:

1here are several Lypes of lnformaLlon needed Lo be recorded whlle Lraclng Lhe sLaLe of a paLlenLs dally
healLh
1 vlLal Slgns 8ody 1emperaLure ulse 8aLe(PearL 8aLe) 8lood ressure and 8esplraLory 8aLe
2 lnLake MedlcaLlon lluld nuLrlLlon WaLer and 8lood eLc
3 CuLpuL 8lood urlne LxcremenL vomlLus and SweaL eLc
4 CbservaLlon of upll slze
3 CapablllLy of four llmbs of body