Professional Documents
Culture Documents
Soapie Charting: Date, Time, and Shift Progress Notes
Soapie Charting: Date, Time, and Shift Progress Notes
(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
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
A – Acute pain related to disease process, soft tissue damage and surgery secondary
to complete comminuted open fracture of distal 3rd right femur.
I-
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.
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
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