S-O-A-P Charting

March, 1978 – 11:30 p.m.

I had just finished walking rounds with the night shift nurse, clocked out, and sat down beside the chart rack to begin my charting before I could go home. I usually was able to complete some of my assigned five patient charts during my shift, but it had been nonstop all evening so I barely had time to gulp down my dinner. Each nurse was assigned five charts and must chart on two of the patient problems before going home. We were not paid overtime to complete our charting.

I wearily began writing using the S-O-A-P format in the heavy 3 inch thick chart under the tab marked “Nurses Notes” with my blue ink pen. Day shift charted in black ink, evening shift used blue ink, and night shift used red ink.

S is for subjective- what the patient says. soap bar

O is for objective – what you observe.

A is for assessment.

P is for plan.

I remembered my college instructor’s words about charting.

“If it’s not charted, it’s not done. Try to paint a concise picture with words of exactly what you did using only approved abbreviations. If you are ever sued, you likely won’t remember the patient several years from now. The lawyers and jury will scrutinize your every word.”

Mrs. K. in Room 515 had had a below the knee amputation two days previously. I scanned her problem list and chose Pain and Diabetes from her list. I began writing using approved abbreviations:

#1. Pain

S: c/o moderate RLE pain. (complains of moderate right lower extremity pain)

O: RLE incision intact. Moderate swelling, slight erythema. VS (vital signs): 99.2-76-18-136/84. (temperature-pulse-respiratory rate-blood pressure)

WBC (white blood cell count) 7.4. Given 2 Percocet.

A: Moderate post-op pain. Pain relieved with Percocet. No sign of infection.

P: Continue to monitor incision qs (every shift), medicate for pain prn (as needed). Instruct pt (patient) about phantom pain.

I completed my last chart at midnight, put on my coat, walked out to the parking lot, climbed in my car, and drove home through the black night.

Reflection

Charting has changed over the years, but the saying of my instructor still holds true in the litigious American society, “If it isn’t charted, it isn’t done.” After Xerox copies were invented, we switched to black ink for charting so the notes were more legible when copies were made.

When I worked in labor and delivery, I had to write my initials and time on the fetal monitor strip whenever I entered the mother’s room, and whenever I gave any medication or did a procedure. Only once was I called to the office of the hospital attorney to review my charting I did on a mother who we sent home in false labor. She later came back that night, but delivered the baby in the hospital parking lot before she made it to the labor and delivery unit. She was now suing the hospital for sending her home, and I was the nurse who did the last assessment. I reviewed my charting about a year after the incident and my instructor’s words came back to my memory. Thankfully, my charting was complete and I never heard the outcome of the lawsuit. They likely settled out of court.

When I was a visiting nurse in the 1990’s, we used a check list system for the daily visits and left a carbon copy in the home for the next nurse. When I worked in the nursing home as a nurse practitioner, we had a dictation service with secretaries which worked very well. We returned once again to the S-O-A-P format. We used both paper charts and electronic medical records which was confusing at times.

In my final job with the federal government, we only had an electronic patient record. The days of heavy paper charts in racks had ceased. I had machine dictation which was only about 70% accurate, so it took quite awhile to correct all the mistakes. But at least we  could read everyone’s notes and never had to go hunting for lost charts. However, when the computer system crashed, it shut down the whole system because we had no access to the patient records. Thankfully, that didn’t happen often. I felt sorry for the providers who had never taken a typing class and had to spend long hours at home in the evening completing their patient’s charts for the day with the old hunt and peck method of typing.

When I called a doctor’s office to request a copy of a patient’s records, his assistant said she would fax them over, but warned me we would not be able to read his handwriting! Over the years, I’m afraid my handwriting has deteriorated also as I have spent countless hours writing in patient charts. Charting isn’t the most satisfying part of nursing, but it is necessary for communication and a required part of every job, so I always tried to do it thoroughly and above all, honestly, to honor God.

“Not with eyeservice, as menpleasers, but as the servants of Christ, doing the will of God from the heart, with good will doing service as to the Lord, and not to men.” Ephesians 6:6-7

When I toured hospitals in China in 1986, I was amazed that they only had one sheet of paper with a few characters on a clipboard hanging on the end of each patient’s bed. The patients were not allowed to sue their provider, so the documentation was very minimal. A Chinese friend told me each person keeps their own medical record in a notebook and takes it with them each time they go to the clinic for the doctor to write in. It sure seems like a much simpler system!

 

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CODE BLUE – TOWER 5!

April, 1977 – Midwest, USA – Orientation

I had just completed my class on handling emergencies including cardiac arrest when I heard the overhead page, “Code Blue, Tower 502, Code Blue, Tower 502, Code Blue, Tower 502!” I was standing in the nurse’s station, so I grabbed the Code Cart and pushed it as fast as I could to Room 502.

Running with the Code Cart!

Running with the Code Cart!

Ann, another nurse on our unit had started to give respirations to Eleanor, a small gray skinned elderly lady I had just talked with the hour before. The doctor and nursing supervisor ran into the room behind me. Miss S., the supervisor, quickly told me to give the medications while she recorded everything the doctor ordered. We grabbed the board off the back of the cart, lifted the patient and put it under her back. Debbie, RN started compressions while Ann grabbed the Ambu bag, hooked it up to the wall oxygen, and placed it over the patient’s face.

Dr B barked at me, “Give 50 cc of Sodium Bicarbonate!” I grabbed the box with the large syringe, tore it open, screwed the plunger on to the syringe, pointed it toward the ceiling, and pushed hard on the plunger to clear the air bubble out of the syringe. Oh, No! I realized that I forgot to remove the needle cap as I saw it go sailing across the room! Dr. B glared at me. My hands started to shake as I grabbed the port of the patient’s intravenous line, pierced it with the needle of the syringe, and began to push the fluid with both thumbs on the plunger as hard as I could through her line. Her body quickly was becoming acidic, so the bicarbonate would counteract this. The Doctor continued to give orders and I pushed the medications through the IV while Ann and Debbie continued respirations and compressions. After 30 minutes, Dr. B. said, “Stop…we lost her.” He turned and left the room.

Everything became quiet. Miss S said, “I’ll call the family while you and the aide wash her body, put a clean gown on her, and clean up the room. Ann removed the code cart from the room and took it down the elevator to the supply department to exchange it for a new cart.

After the aide and I cleaned up Eleanor’s body, I stood alone beside her bed gazing at her. Her face looked relaxed. Her body was still warm. This was the first time I ever saw anyone die. I didn’t know her well, so I don’t know if she had a personal relationship with Christ or not. Silently I prayed, Dear Lord, Use me for your glory and honor. I don’t know how many days I have left here on earth, but You do. Help me to always be ready to meet You. Thank You for saving my soul by your precious blood. Amen

June, 1977 – Evening Charge Nurse

I have now completed orientation and feel like the biggest adjustment is over. It  came to the point where I was daily dreading when the time arrived for me to leave for work. The pressures and responsibilities almost overwhelmed me because all I could hear in my dreams at night was, “Code Blue, Tower 5, Code Blue, Tower 5…” I was so fearful of resuscitating anyone because of the havoc and chaos at my first Code Blue.

I poured out my heart to God and realized I must trust Him, because He is the one who controls life and death, not me! As it says in II Timothy 2:4-5, Who will have all men to be saved, and to come unto the knowledge of the the truth. For there is one God , and one mediator between God and men, the man, Christ Jesus. How God longs for each person to receive Him as their Savior, but He will not force Himself upon anyone.

Now I enjoy going to work every evening, and rest in the Lord to give me the wisdom and strength in every emergency, allowing Him handle it through me! I am just the glove on His hand. How delightful to rest in Him!

And now, the exciting part… the Lord has opened the door for me to teach a Bible class with one of my former patients! One day when I was teaching the class about diabetes, I was able to share the gospel with the patients. Mary listened attentively and asked me to come to her room after class. She shared with me that she also is a Christian and was longing to learn more about the Bible. She lives close to the hospital, so I offered to teach her, and she eagerly said, “Yes!” So every Tuesday morning I go to her home before I go to work and we have the most wonderful time together in the Word.

I was preparing for tomorrow and studying Genesis 22, where Abraham was willing to offer up his only son, Isaac, in obedience to God. He believed that God could resurrect Isaac and was willing to totally obey God in simple faith. I so desire to always obey God like that!

Reflection

Since those days, I have been involved in many Codes for cardiac arrest including infants in labor and delivery and adults when I worked in dialysis and the nursing home. Some nurses enjoy emergencies, but I never have. I am more comfortable having the difficult conversation with elderly terminal patients about their choice of whether or not they want to be resuscitated, and when to choose hospice care. It is a sobering thing to watch someone pass into eternity. But it is truly delightful when I know the person has received Christ as their Savior, and he is welcomed home into heaven above! What grace of our dear Savior to save sinners like us!

Precious in the sight of the Lord is the death of His saints.

Psalm 116:15

 

 

Come Aside and Rest A While

Summer – 1976 – Midwest USA

I started out the summer working as a Nursing Assistant at Children’s Hospital where I had my clinicals last summer. They floated me one day to the burn unit and the nurse asked me to watch her do the dressings on a 2 year old so I could do them the next time with her watching. As a senior nursing student, they allowed me to do some procedures under close supervision. The little boy stood in his crib as she began to unwind his dressings. As the burned skin was exposed, his blood ran down his legs and arms and he began to scream. I felt myself begin to black out and turned and sank into a nearby chair and put my head on my knees. After the blackness cleared, I stood up and went out into the hallway. The nurse finished the dressings and came out into the hallway to speak with me. I said, “I’m so sorry, but I thought I was going to faint. I have never witnessed anything like that before.” She said she understood and told the supervisor not to assign me to the burn unit again. They sent me back to the orthopedic unit where I was last summer. I guess I deal better with the kids in traction than the burned ones.

After 4 weeks of arising at 5 a.m. in order to catch the 6:30 a.m. bus to work, the dizziness, nausea, and weariness was almost unbearable. I could not smile at anyone and my soul was crying in agony to God. I felt like Elijah under the juniper tree crying out to God to take him home. (I Kings 19:4-7) My Pastor was very concerned about me and asked me to take a walk with him before church Sunday night. “Pam, I think you are so rigid right now and have planned everything so much that God can’t work. Let go, and let God do whatever He wants! For one week, don’t plan anything. Take every day as it comes and do everything the opposite you usually do. Go out to a restaurant and eat a meal, listen to the birds, take long walks in the woods. Don’t study your Bible for one week except to read a few verses in the morning.  It will make you a better Bible student in the long run.”

His words were quite a shock to me, but I was willing to try anything since I had lost all joy in the Lord. The next weekend, I drove up to see Jane for one night and we went hiking at the state park. I had to stop every 30 feet to rest a little. When I awoke on Monday, I was still so dizzy and exhausted that I called in sick. After praying about it the rest of the day, I decided I needed to resign and return to my parents’ home to rest the remainder of the summer. I called the head nurse and told her the situation, and she said she understood. After 7 quarters straight of school, with the last one in psychiatry and the demanding classes, my body was beyond exhausted.

My parents were very concerned about me also and were extremely kind to me. After 2 weeks of total rest, I began to feel like myself again and could smile and laugh! I just finished reading a little book by M. R. DeHaan MD called Broken Things. He said, “The Lord only breaks those whom He is going to make.” “Sunshine all the time makes a desert.” I understand better now that I don’t need to strive and push doors open, but just relax and let the Lord open or close the doors. His tenderness in giving me 2 months just to meditate and enjoy Him brings tears to my eyes.

My Dad kindly drove our travel trailer to the state park a couple hours away and set it up so my Mom and I could stay for the week while he returned to work. God has given my Mom and me very precious times together. I so enjoy walking through the woods listening to the rustling leaves, watching the butterflies and dragonflies fly from flower to flower. At night, the chirping crickets lull me to sleep, and the singing birds awaken me every morning. How I thank God for these precious blessings and restoring my health!

Camping at the State Park was so relaxing!

Camping at the State Park was so relaxing!

Reflection

Since 1976, I have had several other times in my life of total exhaustion when I have simply burned the candle at both ends and pushed my body too far.  As I read the passage in I Kings again about Elijah, he had just run for his life 93 miles to flee wicked Queen Jezebel who was trying to kill him! No wonder he was exhausted. After he said to God, “It is enough! Now, O Lord, take away my life; for I am not better than my fathers.” And as he lay and slept under a juniper tree, behold, an angel touched him and said unto him, Arise and eat. And he ate and then slept some more and ate some more. He was able to go 40 days and nights after that. Now I realize I am certainly not Elijah, but the cure was the same for me. Sleep and eat, sleep and eat.

The disciples were deeply grieving after burying their beloved friend, John the Baptist, who was beheaded by wicked King Herod. I love the passage in Mark 6:30-31which says And the apostles gathered themselves together unto Jesus, and told Him all things, both what they had done, and what they had taught. And He said unto them, Come aside into a desert place, and rest a while; for there were many coming and going, and they had no leisure so much as to eat.” It’s so wonderful that our dear Savior sees when we need to rest and provides it for us!

trillium

3 petaled trillium wild flower reminds me of the Trinity!

A restful walk in the woods.

A restful walk in the woods with my sister, Marsha.

January, 2018

I am currently recovering from pneumonia and a horrific reaction to a medicine that put me in the hospital for 12 days. As I slowly regain my strength, I will repeat some of my most popular posts. Please pray for me to learn all the lessons God has for me during this time of recovery. I praise Him that He has made the Bible extremely precious to me as I lean hard on Him. The medicine caused some short term memory loss which was terrifying to me, but God quieted my heart when I remembered 2 Timothy 1:7, “For God has not given us the spirit of fear, but of power, and of love, and of a sound mind.” 

If you have any encouraging Bible verses that you want to share with me and other readers here, please post them in the Comments section. May you have a blessed week of “Looking unto Jesus, the author and finisher of our faith.” Hebrews 12:2.

Pamela, APRN