Question

The nurse assesses a patient postoperatively and charts the findings in a SOAP note. What elements are integral to the SOAP note? Select all that apply.

1) Intervention
2) Order
3) Subjective
4) Assessment
5) Problem

Answer 1

The elements integral to a SOAP note are subjective, objective, assessment, and plan.

Step-by-step explanation:

The elements that are integral to a SOAP note are:

1. Subjective: This includes the patient's subjective feelings, symptoms, and concerns.
2. Objective: This includes the nurse's objective observations, vital signs, and physical assessments.
3. Assessment: This includes the nurse's professional judgment and evaluation of the patient's condition.
4. Plan: This includes the nurse's plan for the patient's care, including interventions, medications, and follow-up.