Documentation or charting format is determined by agency policy and personal preference, if policy allows. Common formats used for charting are SOAPIE, DAR, narrative, and exception.
SOAPIE charting is based on a problem or nursing diagnosis list. Each diagnosis has its own number that never changes. When a SOAP entry is made, it is preceded by the problem or diagnosis number and/or name to which it refers.
Following diagnosis identification, information related to the diagnosis is charted in the following manner:
S (subjective). Anything the patient says; also may include statements made by family members.
O (objective). Observed data; avoid stating opinions: “Just the facts.”
A (analysis) (also known as “assessment”). This is the recorder’s chance to state what he or she “thinks” about what he or she has seen and heard. This is usually done in the form of a diagnosis (nurses use nursing diagnoses).
P (plan). Includes nursing actions implemented or to be implemented. Therapy, teaching, and plans for further assessment are included regarding the diagnosis in A (analysis). The plan states who will implement and when implementation is to take place. (It is important to remember that the reason many things don’t go “according to plan” is that there never was a specific plan.)
The following three categories are sometimes added to the SOAP entry:
I (intervention). Documents implementation if not covered in Plan.
E (evaluation). Documents the effects of the Plan (and intervention if category is used) on the Analysis (diagnosis). It may be entered at a different time from the initial SOAP entry.
R (revisions). Nursing diagnoses, interventions, goals, or outcome dates may be revised in this section.
NOTE: Some institutions have modified SOAP charting significantly. Policies and documentation format acceptable to the institution should be assessed before charting is begun.