The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?
1. S: The client states, "I am so nauseated."
2. O: The client reports feeling fatigued.
3. A: Bowel sounds are high-pitched in all abdominal quadrants.
4. P: The client will remain NPO.
Correct Answer: 2
SOAP charting is a problem-oriented system of documentation. S refers to subjective data; client reports are examples of subjective information. O refers to objective data; objective information is observable by the examiner. Report of fatigue is an example of subjective information. A refers to assessment; the characteristics of the client's bowel sounds represent an assessment. P refers to planning; planning indicates actions taken to resolve or address the client's needs. The client will remain NPO represents an action taken or plan to address the client's needs.
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