Question

a nurse is documenting client care using the soap format. place the statements listed below in the order that the nurse would record them.

Answer 1

The correct sequence will be:

• "I don't feel well. I've been urinating often, and it burns when I urinate."
• Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago.
• Fever, possible urinary tract infection.
• Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor.

Subjective, Objective, Assessment, and Plan are the four headings of a SOAP note. Each heading is explained further below. This is the SOAP note's first heading. Documentation under this heading is based on a patient's or someone close to them's "subjective" experiences, personal views, or feelings.

SOAP notes enable clinicians to record ongoing patient encounters in a structured manner. SOAP notes provide written documentation of what you did and saw. This is significant because it may help you keep track of your scores or goals, may be required by your employer, and in many cases may be critical to getting your work reimbursed by insurance.

To learn more about SOAP format, here

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