Week 9: Charting 101

How Not To Panic Over SOAPIE

aka “Dear Lord, what do I even write in ‘E’?”

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Let’s be honest. When we first learned about SOAPIE in class, it seemed straightforward.

But when you’re actually in the ward, trying to document while being chased by your CI’s “Nasaan na yung chart ni Bed 4?” energy…

That “E” starts looking like “Existential crisis.”

This week, let’s break down how to write a clear, concise SOAPIE note as a student nurse — especially in the OB ward setting. Let’s make charting less nakaka-praning and more doable.

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Quick Recap: What is SOAPIE?

• S – Subjective data (what the patient says)
• O – Objective data (what you observe)
• A – Assessment (your interpretation)
• P – Plan (what needs to be done)
• I – Intervention (what you actually did)
• E – Evaluation (was it effective?)

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Sample SOAPIE: Postpartum Mom with Breast Engorgement

🟪 S:

"Masakit po ang dibdib ko, parang puno na puno na."

🟪 O:

Breasts noted to be engorged, warm, and tense upon palpation. Mother appears uncomfortable.

🟪 A:

Breast engorgement secondary to delayed breastfeeding initiation.

🟪 P:

Encourage frequent breastfeeding, warm compress prior to feeding, and proper latch technique.

🟪 I:

Assisted mother with warm compress and positioning for latch. Educated on feeding every 2–3 hours.

🟪 E:

Mother verbalized decreased discomfort post-feeding. Breast appears softer. Plan to continue intervention.

🎯 Pro tip: If you can’t fill out “E” right away, leave space and return later when reassessment is done.

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Common OB Ward Scenarios You Can SOAPIE

1. Uterine atony post-delivery
2. Pain on perineal sutures
3. Difficulty latching baby
4. Patient anxious about baby’s jaundice
5. Elevated BP in postpartum mom

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Tips para ‘di ka na ma-paralyze sa SOAPIE writing

🟣 1. Use patient’s own words for "S"

Even simple quotes like “Parang may lagnat si baby” are valid.

🟣 2. For “O”, think nursing observations

Vital signs, fundic height, lochia, behavior, breastfeeding — these count!

🟣 3. Your “A” doesn’t need to sound like a doctor’s diagnosis

You can say: “Possible postpartum blues” or “Breast engorgement noted” — it's still assessment.

🟣 4. “P” and “I” must match

Plan what you intend to do, and under “I”, show that you did it. Don’t write “educate” if you didn’t actually explain.

🟣 5. “E” is where most students freeze

Just ask: “Nagbago ba after ginawa ko?”

If yes → write the outcome. If no → note that, too.

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When in Doubt… Ask Your CI (Before You Submit)

They’d much rather help fix a SOAPIE draft than have to give you the “Bakit parang wala kang inobserbahan?” stare.

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To My Fellow Student Nurses

Charting isn’t just paperwork. It’s proof of care — your voice in the clinical record.

So even if you’re just starting out, your notes matter.

They reflect your growing skills, your compassion, and your responsibility.

“Kung ginawa mo, isulat mo. Kung sinulat mo, panindigan mo.” 

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