Answer Happy

E An evaluation stating how the patient responded to the illness and reacted to the treatment, medications, and medical care. SOAPIE Another system added intervention and its evaluation: Implementation or how the actions were carried out: an approach to a particular problem. The evaluation or the report of the actual patient outcome or the response of subsequent treatment. SOAPIER Other components to the SOAP system of charting include intervention, evaluation, and revision. Implementation or the approach to a particular problem. Evaluation looks at the patient's response to the treatment intervention. Revision identifies changes that are prompted by the evaluation. R PIE PIE (Problem-Intervention-Evaluation) charting was introduced in 1984 at the Craven Regional Medi- cal Center in North Carolina. With this method, problems are identified and addressed at least once on every shift. Teaching plans are incorporated in the progress notes. Notes must be read often to under- stand the evolution of the problems and the effectiveness of the treatment. Examples р Problem: Patient hasn't had bowel movement for 3 days. i Intervention: Telephone order for Dulcolax® 2 tablets at 8 am E Evaluation: Patient had a bowel movement in afternoon. Whatever system your office or institution follows is the system one needs to utilize for progress note, documentation, patient achievements, charting in the medical record, or the electronic medical record.