SOAPIE CHARTING

(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

DATE, TIME, AND PROGRESS NOTES

SHIFT

S- Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”; first pregnancy,
unintended but wanted; separated from the baby’s father for 7 months; close
female friend as SO; no relatives present; attended preparation for labor classes
with a friend as coach---------------------------------------------------------------------GERALI
November 30, 2020
7:30AM
7AM-11PM O- None------------------------------------------------------------------------------GERALI

A- Risk for ineffective coping regarding fear, anxiety and powerlessness-------------

-------------------------------------------------------------------------------------------------GERALI

P- After 8hrs, she will exhibit appropriate coping mechanisms and cooperate
with the support person/s and nursing staff; and be able to make informed
decisions regarding treatment options----------------------------------------------- GERALI

I- Assessed for the presence of defining characteristics; assessed for signs and
symptoms of ineffective coping; observed causes of ineffective coping (e.g. poor
self-concept, lack of problem-solving skills, lack of support, or recent change in life
situation; helped the client seek realistic goals and identify personal skills and
knowledge; used empathetic communication and encouraged pt. to verbalize
fears, express emotions, and set goals, and be informed of labor progress and
fetal well- being; assisted in identifying situations that the pt. does have control
over (e.g. positioning, pain control methods, relaxation techniques); encouraged
decision making and participation in planning of care and scheduled activities;
encouraged the pt. to describe previous stressors and the coping mechanisms
used; referred pt. for counseling as needed---------------------------------------- GERALI

E- Goal Met: After 8hrs, pt. exhibited signs of calm when asking questions
regarding labor progress as well as compliance with protocol procedures; also
expressed her preferences during labor ---------------------------------------------GERALI

MGCG, SN

Patient SH / Room No. | 1

 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

DATE, TIME, AND PROGRESS NOTES

SHIFT

S- Pt. treated twice for trichomoniasis last year, 2019-------------------------- GERALI

O- Received at DR with D5LR @20 gtts/min; T: 37.4; P: 100 bpm; BP: 120/80
mmHg; R: 21 cpm; O2 Sat: 98%; ROM @ 4:00 AM, an hour prior to admission;
contractions: 2 in 10 in the last 25sec; last meal: 8 hours prior to admission---------
November 30, 2020 ------------------------------------------------------------------------------------------------- GERALI
7:30AM
7AM-11PM A- Risk for infection r/t rupture of amniotic membranes------------------------- GERALI

P- Within 8hrs, Pt. will remain free of infection as evidenced by normal vital signs
and absence of signs and symptoms of infection--------------------------------- GERALI

I- Assessed immunization status and history; monitored signs and symptoms of

infection such as redness, swelling, increased pain, purulent discharges from
rupture: (a) change in color, consistency, and amount of vaginal discharge, (b)
urinary frequency; dysuria; cloudy; foul-smelling urine, (c) monitored temperature,
report single temperature greater than 100.5 F; assessed the presence of local
infectious processes in the skin or mucous membranes; assessed vaginal
discharge for odor; monitored WBC count; maintained strict asepsis (e.g. catheter
and IV site handling); executed proper handwashing before having contact with
the patient; imparted these duties to the patient’s SO---------------------------------------
------------------------------------------------------------------------------------------------- GERALI

E- Goal Met: After 8hrs, she remained free of infection as evidenced by normal vital
signs and absence of signs and symptoms of infection------------------------------------------------
----------------------------------------------------------------------------------------------------------- GERALI

MGCG, SN

Patient SH / Room No. | 2

 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

DATE, TIME, AND PROGRESS NOTES

SHIFT

S- Last ate toast and coffee eight hours ago-------------------------------------- GERALI

O- Received at DR with D5LR @20 gtts/min; T: 37.4,P: 100 bpm; BP: 120/80
mmHg; R: 21 cpm; O2 Sat: 98%; Urine output: 150mL, 200mL--------------------------
November 30, 2020 ---------------------------------------------------------------- ------------------------------ GERALI
7:30AM
7AM-11PM A- Risk for fluid volume deficit r/t prolonged lack of oral intake and diaphoresis d/t
labor process------------------------------------------------------------------------------ GERALI

P- Within 8hrs, pt. will have adequate fluid volume as evidenced by normal vital
signs, normal urine output and absence of signs and symptoms of dehydration;
verbalizes awareness of causative factors and behaviors essential to correct fluid
deficit; and be free of complications-------------------------------------------------- GERALI

I- Assessed and recorded: IV fluids and condition of IV site every hour and RR,
HR, BP and T every 4hrs and PRN signs/symptoms of deficient fluid volume every
4 hours and PRN; assessed and documented the onset, intensity, character,
location, duration, aggravating factors, and relieving factors; assessed skin turgor
and oral mucous membranes for signs of dehydration--------------------------------------
------------------------------------------------------------------------------------------------ GERALI

E- Goal Met: After 8hrs, she demonstrated adequate fluid volume as evidenced
by normal vital signs with oxygen saturation between 95% -100% , temperature
range of 36.5*C to 37.2*C, heart rate within 100 bpm, urine output higher than 30
mL , and displayed negative signs and symptoms of dehydration-----------------------
------------------------------------------------------------------------------------------------- GERALI

MGCG, SN

Patient SH / Room No. | 3

 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

28 y/o Sex: ________

Age: _______ F Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”
CC: ___________________________________________________________________
Medical Diagnosis: _________________________________________________________________________________
G1PO; AOG @ 39 weeks; membranes ruptured; in labor

DATE, TIME, AND PROGRESS NOTES

SHIFT

S- Pt. verbalized, “I’m in labor. Tell me what I’m supposed to do.”; attended
preparation for labor classes with a friend as coach-----------------------------------------
------------------------------------------------------------------------------------------------- GERALI

November 30, 2020 O- None------------------------------------------------------------------------------------- GERALI

7:30AM
7AM-11PM A- Health-seeking behaviors r/t management of labor discomfort ----------------------
------------------------------------------------------------------------------------------------- GERALI

P- Within 4hrs, pt. will demonstrate appropriate breathing and relaxation

techniques, and participate in decision-making process ----------------------- GERALI

I- Assessed pt’s baseline knowledge; reiterated information about procedures and

normal progression of labor; educated the client about breathing and relaxation
techniques appropriate to each phase of labor; taught and reviewed pushing
positions for stage II-----------------------------------------------------------------------GERALI

E- Goal Met: After 8hrs, she demonstrated appropriate breathing and relaxation
techniques, and participated in the duration of the decision-making process
concerning her pregnancy---------------------------------------------------------------GERALI

MGCG, SN

Patient SH / Room No. | 4