SOAPIE.docx - 1 What is a SOAPIE note A SOAPIE note is a method of documentation that is used to write out notes in a patient’s chart The information

SOAPIE.docx - 1 What is a SOAPIE note A SOAPIE note is a...

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1) What is a SOAPIE note? A SOAPIE note is a method of documentation that is used to write out notes in a patient’s chart. The information that is written or presented about a patient is written in a specific order. It is used for admission notes, medical histories or other documentation that is in the patient’s chart. Depending on what area you are working in, you will either use SOAP, SOAPIE, or SOAPIER. 2) Give an example of a SOAPIE note. S: subjective O: objective A: Assessment/Analysis P: Plan I: Implementation E: Evaluation S: I have been having pain in my side for several hours and it has not eased up any. O: Patient is not anxious and appears to be in a great deal of pain trying to put pressure
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Unformatted text preview: on the side where the pain is located T: 98.4 HR: 105 BP: 115/80 RR: 16 Pain 8/10 A: Pain seems to be urinary related, possible kidney stone to an infection as the pain is persistent. P: Perform a CT to check for possible kidney stones or blockage in the ureter that could be causing the pain. Plenty of rest along with a lot of fluids. Pain meds as needed. I: Completed the CT. It did show a stone approximately 3mm in size. Administered 2.5mg of Dilaudid IVP for pain. E: After receiving the 2.5mg Dilaudid IVP the Pt states the pain is now at a 2/10. Pt is in less pain and referred to the Urologist for a follow-up....
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