Glossary entry (derived from question below)
Spanish term or phrase:
A, P, I = Análisis, Plan, Intervención
English translation:
S O A P I = Subjective, Objective, Analysis, Plan and Intervention
Added to glossary by
Taña Dalglish
Sep 26, 2023 12:46
8 mos ago
26 viewers *
Spanish term
United States
All languages are bridges.
Native in: English
Works in: Spanish to English, Quechua to English, English to Spanish, and 3 more.
"A"; "P"; "I"
Spanish to English
Medical
Medical: Health Care
Peruvian emergency room r
Good morning. My Peruvian hospital care report project is winding down; thanks for everyone's input!
I've got a few final questions. One of them has to do with the above list of initials. They're found in the "Evolución de Enfermería" section of the Emergency Room clinical history. They´re found in a list of steps taken to initially diagnose the patient. Here's the immediate context:
S: Paciente con dolor tipo opresivo en abdomen
O: Paciente de sexo feminino quejumbrosa, palida, abdomen B/D a la palpación
A: Dolor agudo R/C agente biológico
P: Paciente disminuirá el dolor progresivamente con TTO
I: CFV
Se le brinda educación sobre tratamiento
My efforts so far: "S" would be for "symptoms", and "O" for "operation", although I've been using "transactions" for the sales receipts. However, I'm not sure about the remaining initials: "A", "P" and "I".
As always, a thousand thanks!
I've got a few final questions. One of them has to do with the above list of initials. They're found in the "Evolución de Enfermería" section of the Emergency Room clinical history. They´re found in a list of steps taken to initially diagnose the patient. Here's the immediate context:
S: Paciente con dolor tipo opresivo en abdomen
O: Paciente de sexo feminino quejumbrosa, palida, abdomen B/D a la palpación
A: Dolor agudo R/C agente biológico
P: Paciente disminuirá el dolor progresivamente con TTO
I: CFV
Se le brinda educación sobre tratamiento
My efforts so far: "S" would be for "symptoms", and "O" for "operation", although I've been using "transactions" for the sales receipts. However, I'm not sure about the remaining initials: "A", "P" and "I".
As always, a thousand thanks!
Proposed translations
(English)
| 2 +2 | S O A P I |
Taña Dalglish
|
| 4 +2 | Analisis Plan e Implementación |
Iker Pellicer
|
Change log
Oct 10, 2023 07:57: Taña Dalglish Created KOG entry
Proposed translations
+2
4 hrs
Taña Dalglish
Jamaica
Jamaica
Native in English
Works in field
Jamaica
Translating the Ideas Behind the Words
Native in: English (Variant: British)
Works in: Spanish to English, English to Spanish, French to English, and 2 more.
Related KudoZ points
:
60
Selected
S O A P I
I believe the language required is English.
"S O A P I" x Subjective, Objective, Analysis, Plan and Intervention.
--------------------------------------------------
Note added at 13 days (2023-10-10 07:54:11 GMT) Post-grading
--------------------------------------------------
Thank you, Julie.
"S O A P I" x Subjective, Objective, Analysis, Plan and Intervention.
--------------------------------------------------
Note added at 13 days (2023-10-10 07:54:11 GMT) Post-grading
--------------------------------------------------
Thank you, Julie.
4 KudoZ points awarded for this answer.
Comment: "Selected automatically based on peer agreement."
+2
14 mins
Iker Pellicer
Spain
Spain
Native in Spanish
Works in field
Spain
Imagine. Translate.
Native in: Basque 
, Spanish
Works in: Spanish to Basque, Basque to Spanish, English to Basque, and 6 more.
Analisis Plan e Implementación
Subjetivo: la documentación debe incluir lo que dice el paciente o información que sólo el paciente puede proporcionar personalmente. Esto debe incluir dolor percibido, síntomas como sensación de entumecimiento u hormigueo, antecedentes médicos y familiares y alergias. Esta información se recopila haciendo preguntas al paciente y es importante registrarla exactamente como el paciente informa.
Objetivo: registrar lo que la enfermera observa, oye, ve y siente durante la evaluación del paciente. Los tipos de evaluaciones realizadas dependen del centro en el que se encuentra el paciente (paciente hospitalizado o ambulatorio) y de los diagnósticos médicos y las quejas del paciente.
Análisis: después de recopilar datos de evaluación subjetiva y objetiva, la enfermera debe realizar un análisis inicial de la condición del paciente e identificar cualquier diagnóstico de enfermería apropiado.
Plan: una vez identificado un diagnóstico de enfermería inicial, la enfermera debe crear un plan de acción. Esto puede incluir reposicionamiento, solicitar analgésicos a los proveedores, aplicar oxígeno según el protocolo o brindar apoyo emocional. El plan debe estar centrado en el paciente y basado en los diagnósticos de enfermería.
Implementación: una vez decidido el plan de acción, se deben poner en marcha las acciones (intervenciones). A veces, el plan de una enfermera no sale exactamente como lo planeó y eso es de esperarse. Es importante documentar todas las intervenciones realizadas, e incluso las que se intentaron.
Objetivo: registrar lo que la enfermera observa, oye, ve y siente durante la evaluación del paciente. Los tipos de evaluaciones realizadas dependen del centro en el que se encuentra el paciente (paciente hospitalizado o ambulatorio) y de los diagnósticos médicos y las quejas del paciente.
Análisis: después de recopilar datos de evaluación subjetiva y objetiva, la enfermera debe realizar un análisis inicial de la condición del paciente e identificar cualquier diagnóstico de enfermería apropiado.
Plan: una vez identificado un diagnóstico de enfermería inicial, la enfermera debe crear un plan de acción. Esto puede incluir reposicionamiento, solicitar analgésicos a los proveedores, aplicar oxígeno según el protocolo o brindar apoyo emocional. El plan debe estar centrado en el paciente y basado en los diagnósticos de enfermería.
Implementación: una vez decidido el plan de acción, se deben poner en marcha las acciones (intervenciones). A veces, el plan de una enfermera no sale exactamente como lo planeó y eso es de esperarse. Es importante documentar todas las intervenciones realizadas, e incluso las que se intentaron.
Peer comment(s):
| agree |
Lirka
: yes, the good old SOAP note, with an added "I" :=)
1 hr
|
| agree |
Chema Nieto Castañón
6 days
|
Reference comments
27 mins
Taña Dalglish
Jamaica
Jamaica
Native in English
Works in field
Jamaica
Translating the Ideas Behind the Words
Native in: English (Variant: British)
Works in: Spanish to English, English to Spanish, French to English, and 2 more.
Related KudoZ points
:
60
Reference:
https://blog.gorendezvous.com/en/what-is-a-soap-note
Julie:
I am really unsure if relevant, but leave you with this as this is not my area of expertise: https://blog.gorendezvous.com/en/what-is-a-soap-note. In your case "S O A P I":
The SOAP, SOAPIE, or SOAPIER notes are well known in the health field, they are used by physiotherapists, chiropractors, osteopaths, massage therapists, occupational therapists, and many others. They allow professionals to enter all relevant patient information in a standardized and easy-to-read manner. This way, all health professionals will be kept informed of the patient’s condition, the various appointments, and the progress.
We start with the SOAP format, then we can add the IE and finally the R as needed:
SOAPIER
**Subjective**: This is the part where the patient’s observations are recorded. Here, we can find their symptoms, family history, old injuries, lifestyle, health history, etc. It is also possible to include the goal the patient wants to reach with the consultations.
**Objective**: Here you can find information that does not change such as biological sex, age, blood type, apparent injuries, etc.
**Analysis**: This part will contain the professional’s analysis of the data from the subjective and objective parts. This section contains the list of issues, reasoning, treatment goals, treatment direction, etc. It’s where you can do an assessment of a patient’s needs and analyze additional factors that may interfere with the treatment plan to draw conclusions.
**Plan**: Here, you can decide on the plan to adopt in order to achieve the goal set with the patient. You can indicate the duration of the treatment and its frequency, the strategies adopted, and a description of the overall treatment.
**Intervention**: It’s where you can add the interventions carried out since the beginning of the implementation of the plan. Each intervention can be mentioned in detail, it can also include the training prescribed to the patient if there is any.
**Evaluation**: This part includes the evaluation of the effectiveness of the interventions, how the patient reacts, if they see improvements, etc.
************************
Revision: The revision part allows you to see if you should change the plan or readjust it according to the results obtained so far.
I am really unsure if relevant, but leave you with this as this is not my area of expertise: https://blog.gorendezvous.com/en/what-is-a-soap-note. In your case "S O A P I":
The SOAP, SOAPIE, or SOAPIER notes are well known in the health field, they are used by physiotherapists, chiropractors, osteopaths, massage therapists, occupational therapists, and many others. They allow professionals to enter all relevant patient information in a standardized and easy-to-read manner. This way, all health professionals will be kept informed of the patient’s condition, the various appointments, and the progress.
We start with the SOAP format, then we can add the IE and finally the R as needed:
SOAPIER
**Subjective**: This is the part where the patient’s observations are recorded. Here, we can find their symptoms, family history, old injuries, lifestyle, health history, etc. It is also possible to include the goal the patient wants to reach with the consultations.
**Objective**: Here you can find information that does not change such as biological sex, age, blood type, apparent injuries, etc.
**Analysis**: This part will contain the professional’s analysis of the data from the subjective and objective parts. This section contains the list of issues, reasoning, treatment goals, treatment direction, etc. It’s where you can do an assessment of a patient’s needs and analyze additional factors that may interfere with the treatment plan to draw conclusions.
**Plan**: Here, you can decide on the plan to adopt in order to achieve the goal set with the patient. You can indicate the duration of the treatment and its frequency, the strategies adopted, and a description of the overall treatment.
**Intervention**: It’s where you can add the interventions carried out since the beginning of the implementation of the plan. Each intervention can be mentioned in detail, it can also include the training prescribed to the patient if there is any.
**Evaluation**: This part includes the evaluation of the effectiveness of the interventions, how the patient reacts, if they see improvements, etc.
************************
Revision: The revision part allows you to see if you should change the plan or readjust it according to the results obtained so far.
Peer comments on this reference comment:
| agree |
slothm
5 hrs
|
|
Thank you.
|
|
| agree |
Chema Nieto Castañón
6 days
|
|
Gracias Chema.
|
6 days
Chema Nieto Castañón
Spain
Spain
Native in Spanish
Specializes in field
Spain
Psychologist & Emergency Physician
Native in: Spanish (Variant: Standard-Spain)
Works in: English to Spanish
Related KudoZ points
:
62
Reference:
SOAPIE charting
To help with accurate and thorough documentation skills, try following the SOAPIE method. There is an older version of SOAPIE notes, which are SOAP notes.
https://www.nursetogether.com/soapie-charting-nursing-notes-...
https://www.nursetogether.com/soapie-charting-nursing-notes-...
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