Question

Create SOPA note for

A 78 years female is admitted to the unit with the symptom of early dementia and depression. The patient states, “I cannot remember where I put my neckless, glasses, and rings. I keep losing my belongings. When I am out alone, I cannot find my house.” She also reports she cannot decide what to wear and what to do quickly. Her decision-making process takes a long time for daily tasks like preparing breakfast. The patient looks confused and frustrated, but her vital signs are normal.

Answer 1

A SOAP note is information about the patient, which is written or presented in a specific order, which includes certain components :-

- subjective

- objective

- assessment

- plan

Nurses make notes for each of these elements in order to provide clear information to other healthcare professionals.

SOAP note for this patient :-

S - Subjective data includes data which is provided by the patient . In this case the patient states that she cannot remember where she put her neckless, glasses, and rings. She keep losing her belongings. When she is out alone, she cannot find her house.” She also reports she cannot decide what to wear and what to do quickly.

O - Objective data includes the data which is observable . The patient seems to be confused and frustrated . Her vital signs were normal.

A - Assessment includes what all assessment needs to be done for this patient . MSE , a thorough physical examination and routine blood investigations

P - Plan includes planning management care for the patient based on the needs of the patient . Medications such as antidepressants will be prescribed for her .