u observe or see A-assessment, What do you think is going on based on your data P-planning, what are you going to do? What are your expected outcomes?…

Question SOAPIE Method of documentation S- subjective, what the patient tellsyouO- objective, what you observe or seeA-assessment, What do you think is going on based on your dataP-planning, what are you going to do? What are your expected outcomes?I-intervention, specific interventions are implementedE-evaluation, patient’s response to the interventions Crystal has been diabetic for 10 years now and continues to struggle with good blood sugar control. She states “I feel lethargic all the time. I don’t understand why my blood sugar is so high in the morning when I barely eat anything.” Her fasting blood sugars range from 201-320 within the last week. She reports occasionally eating cinnamon toast crunch (a cereal high in simple sugars) throughout the day and when she is bored. She reports, however, that she feels she is eating pretty well indicating the many bottles of juice in her fridge. You also notice candy bars and donuts on the kitchen counter. The client appears to be on a high carbohydrate diet, some protein, and no signs of any whole foods. Her BMI was reported to be 35 at her last doctor’s visit. You decide that Crystal should be seen by a nutritionist to help her construct a meal plan to help her adhere to a diet focused on complex carbohydrates, adequate fats and proteins. Crystal also reports that she is having more numbness and tingling sensations to her lower extremities. Looking over her medication list, she doesn’t appear to be on any medications for neuropathy (a symptom of diabetes). You call the physician and get her started on Gabapentin daily.After 2 weeks, Crystal has met with a nutritionist twice and has adjusted some of her eating habits. Her fasting blood sugar is now in the 180-220. She has started adding more protein into her diet, added more whole fruits and vegetables, and involved her sister to help her meal prep. She reports that the gabapentin has helped tremendously and she no longer gets the feeling of pins and needles to her lower extremity. Please use the information above to document using the SOAPIE method. S O A P I E Health Science Science Nursing NUR MISC Share QuestionEmailCopy link Comments (0)