Lorraine Poulos

61 Documentation When documenting changes in clinical care or a condition staff should consider following the well-known SOAP documentation method. S - Subjective - What is reported by the worker or consumer i.e. a general summary of the situation. O - Objective - What are the facts? Such as observations, measurements e.g. blood pressure, skin colour, urinalysis, blood sugar levels, condition of a wound. A - Assessments or Actions - What actions need to be taken or where undertaken, what assessments might need to be undertaken, e.g. referral to GP, X rays. It may be instructions for staff to report certain changes. P - Plan - What is the final plan? Once the SOA have been determined, a final summary of actions and plans should be recorded. This should, where possible, have a time frame included and any follow up action by the provider. Remember throughout the documentation process the needs, desires and goals of the consumer must be considered.