Question

A nurse documents the following patient data in the patient record according to the SOAP format: Patient complains of unrelieved pain; patient is seen clutching his side and grimacing; patient pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

A. PIE Charting
B. Focus Charting
C. SOAP Charting
D. Narrative Charting

Answer 1

The correct answer to the student's question is C. SOAP Charting, which stands for Subjective, Objective, Assessment, and Plan. This format helps health professionals document patient information in a structured way.

Step-by-step explanation:

The charting method exemplified in the student's question is SOAP Charting. SOAP is an acronym for Subjective, Objective, Assessment, and Plan. This format is used by healthcare professionals to organize and record information in a patient's chart. In the scenario provided:

• Subjective: The patient's complaint of unrelieved pain is the subjective input, which is what the patient feels and describes.
• Objective: The observation of the patient clutching his side and grimacing represents objective data that can be observed and measured by the nurse.
• Assessment: The nurse's assessment that the patient's pain medication does not appear to be effective is an evaluation based on the subjective and objective information gathered.
• Plan: The nurse's call to the primary care provider to increase the dosage of pain medication or change the prescription is the plan of action following the assessment.

So the correct answer to the question is C. SOAP Charting.