A nurse is documenting in a client’s health record using the subjective, objective, assessment, and plan (SOAP) charting model.
Which of the following information should be included in the subjective component?
A.
Client reports chest pain after mowing lawn this morning.
B.
Client’s blood pressure is 182/98 mm Hg.
C.
Client administered nitroglycerin 0.3 mg SL for chest pain.
D.
Client’s skin is pale and diaphoretic.
The Correct Answer and Explanation is:
The correct answer is A. Client reports chest pain after mowing lawn this morning.
Explanation:
The SOAP charting model is a widely used format for documenting patient information in medical records. It stands for Subjective, Objective, Assessment, and Plan, each of which plays a distinct role in capturing and organizing information about the client’s health status.
- Subjective (S): This component includes information reported directly by the client. It encompasses their personal experiences, feelings, and perceptions about their condition. The subjective information is essentially what the patient tells the healthcare provider and can include symptoms, complaints, and the impact of those symptoms on their daily life. In this case, option A, “Client reports chest pain after mowing lawn this morning,” is subjective because it reflects the client’s own report of their experience. This information is crucial as it provides insight into the client’s symptoms, their onset, and any potential triggers or activities that may have contributed to their current condition.
- Objective (O): This part of the charting model includes measurable and observable data collected by the healthcare provider. It consists of physical examination findings, laboratory results, vital signs, and other quantifiable data. Options B and D fall under this category. Option B, “Client’s blood pressure is 182/98 mm Hg,” and option D, “Client’s skin is pale and diaphoretic,” are both objective observations made by the nurse or healthcare provider.
- Assessment (A): This component involves the healthcare provider’s clinical judgment about the client’s condition based on the subjective and objective information. It includes diagnoses or potential diagnoses, as well as the analysis of the client’s condition.
- Plan (P): The plan outlines the steps for addressing the client’s issues. It includes treatments, interventions, and follow-up plans based on the assessment.
In summary, option A is the subjective component because it represents the client’s personal experience of chest pain, which is reported in their own words. This information is essential for understanding the client’s perspective and guiding the subsequent assessment and planning.