In the SOAP format, which information belongs in the assessment section?
Correct answer: C. Nurse concludes that dehydration is suspected
- A. Patient reports nausea after breakfast
- B. Blood pressure is 90/58 mmHg
- C. Nurse concludes that dehydration is suspected
- D. Encourage oral fluids as tolerated
Explanation
The assessment section contains the nurse’s clinical interpretation of the subjective and objective findings. The patient report is subjective data, the blood pressure is objective data, and encouraging fluids is part of the plan.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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