Soapie Charting: Date, Time, and Shift Progress Notes

SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)
Age: 44 y.o. Sex: Male CC: Gunshot wound, POE: Right lateral thigh,POX: Right medial thigh
Medical Diagnosis: Fracture, Open IIIA, complete, comminuted,distal 3rd, femur right
DATE, TIME, AND PROGRESS NOTES

SHIFT
S-
11/23/20 9 hours PTA, patient was shot by a police officer by means of self-defense. Patient
sustained a gunshot wound on the right thigh. Chief Complaint of Gunshot wound,
7am-3pm
POE: Right lateral thigh, POX: Right medial thigh
Sakit pa jud ug e lihokakongtiil”

7am
“Ok ra man ko diri, igang ra jud, boring. Dili ko ka sugal. Lisodkynaakoysamad, gipusil
baya ko ay”
O-(+) Periorbital hematoma noted on both eyes with subconjunctival hemorrhage on

left eye due to alleged mauling.Presence of wound scars on right arm; nails on both
hands are not trim. (+)Swelling noted on right knee and thigh; pain was reported by the
patient with a pain scale of 8/10. Intramedullary bone pins are transversely inserted on
proximal 3rd right tibia with 10 kgs skeletal traction in place. muscle grade strength ⅗ at
R leg, ⅘ @ L leg. Pt was diagnosed with Fracture, Open IIIA, complete, comminuted,
distal 3rd, femur right and had undergone Debridement thigh, leg, application of delta
right leg and power transitional pin on March 23, 2021.
A – Acute pain related to disease process, soft tissue damage and surgery secondary
to complete comminuted open fracture of distal 3rd right femur.
P-After 8 hours of nursing interventions, the pt will be able to:
 Verbalize method that provide relief

 Demonstrate use of relaxation skills and diversional activities
After 3 days of nursing interventions, the pt will be able to:
 Report pain is relieved/controlled, with a pain scale of 3-4/10 from 8/10

 Verbalize understanding of the condition
I-
 Provide measures to relieve pain before it becomes severe.

 Acknowledge and accept the client’s pain.
 Use nonpharmacological pain relief methods (relaxation exercises, breathing
exercises, music therapy).
 Provide optimal pain relief by administering prescribed pain relief medication.
 Provide a quiet environment.
 Reposition the patient in his comfortable/preferred position
 Document patient’s response to pain management.
E-
Ideally: Goal must be fully or partially met. It was not indicated in the case how the pt
responded after implementing the nursing interventions.
Patient’s Name / Room No.| 1

After 8 hours of nursing interventions, the ptwas able to:
 Verbalize method that provide relief

 Demonstrate use of relaxation skills and diversional activities
After 3 days of nursing interventions, the ptwas able to:
 Report pain is relieved/controlled, with a pain scale of 3-4/10 from 8/10

 Verbalize understanding of the condition

FDAR CHARTING
(Focus-Data-Action-Response)
Age: 44 y.o. Sex: Male CC: Gunshot wound, POE: Right lateral thigh,POX: Right medial thigh
Medical Diagnosis: Fracture, Open IIIA, complete, comminuted,distal 3rd, femur right
Date, Time, and FOCUS PROGRESS NOTES

Shift
11/2/30
7AM-3PM
D- Received pt awake, lying on bed, in a supine position,
7am Pain conscious, coherent, oriented to time, person, place,
responsive but lethargic, no signs of distress and poorly
groomed. 9 hours PTA, patient was shot by a police officer
by means of self-defense. Patient sustained a gunshot
wound on the right thigh. It was reported that he went
hysterical and threatened his wife and 2 kids with a knife
then attacked the police officer thereafter. Patient was also
reported to have a mental illness.(+) Periorbital hematoma
noted on both eyes with subconjunctival hemorrhage on left
eye due to alleged mauling.Pt has a weight of 60 kg. Vital
signs as follows PR: 80 bpm, RR: 20 cpm, BP: 110/80
mmHg, O2 Saturation: 97%.“Sakit pa jud ug e
lihokakongtiil” as verbalized by the pt;(+)Swelling noted
onright knee and thigh; pain was reported by the patient
with a pain scaleof 8/10. Intramedullary bone pins are
transversely inserted on proximal3rd right tibia with 10 kg
skeletal traction in place. -------------------------------------KMBL
A- Maintain immobilization of affected part by means of

bed rest, splint, and traction.Elevate and support injured
KMBL
extremity.Avoid use of plastic sheets and pillows under
Karl Marlu B. Luza, limbs in cast.Elevate bed covers; keep linens off
SN MSU-IIT toes.Evaluate and document reports of pain or discomfort,
noting location and characteristics, including intensity (0–10
scale), relieving and aggravating factors. Note nonverbal
pain cues (changes in vital signs, emotions and behavior).
Listen to reports of family members or SO regarding
patient’s pain.Encourage patient to discuss problems
related to injury.Explain procedures before beginning
them.Medicate before care activities. Let patient know it is
important to request medication before pain becomes
severe.Perform and supervise active and passive ROM
exercises.Provide alternative comfort measures (massage,
backrub, position changes). Identify diversional activities
appropriate for patient age, physical abilities, and personal
preferences.Apply cold or ice pack first 24–72 hr and as
necessary. Administer Tramadol 50 mg IVTT PRN for pain
as prescribed by the physician. ----------------------------KMBL
R-Display relaxed manner; able to participate in activities,

sleep/rest appropriately.Demonstrate use of relaxation skills
and diversional activities as indicated for individual
situation. Reports satisfactory pain control and pain scale is
reduced from 8 to 4.--------------------------------------------KMBL

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SOAPIE CHARTING

DATE, TIME, AND PROGRESS NOTES

Sakit pa jud ug e lihokakongtiil”

O-(+) Periorbital hematoma noted on both eyes with subconjunctival hemorrhage on

P-After 8 hours of nursing interventions, the pt will be able to:

 Verbalize method that provide relief

After 3 days of nursing interventions, the pt will be able to:

 Report pain is relieved/controlled, with a pain scale of 3-4/10 from 8/10

 Provide measures to relieve pain before it becomes severe.

Patient’s Name / Room No.| 1

 Verbalize method that provide relief

After 3 days of nursing interventions, the ptwas able to:

 Report pain is relieved/controlled, with a pain scale of 3-4/10 from 8/10

Patient’s Name / Room No.| 2

Date, Time, and FOCUS PROGRESS NOTES

A- Maintain immobilization of affected part by means of

R-Display relaxed manner; able to participate in activities,

Patient’s Name / Room No.| 3

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