Use of SOAPIER format in rotating interns of the Nursing career

Viviana Lissette Peña Ramón, Fabiola Beatriz Chasillacta Amores
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Abstract

Introduction: the format SOAPIER is a systematic structure used for recording and interpreting the problems and care that the patient deserves. Objective: Identify the use of the SOAPIER format in rotating interns of the Nursing Career of the Technical University of Ambato. Methods: The research has a cross-sectional quantitative-descriptive approach. The sample consisted of 78 rotating inmates; a modified questionnaire was applied and validated by experts, with a Cronbach's Alpha of 0.811, thus guaranteeing the reliability of the instrument. Results: The 75.6% apply the recording of subjective data, as do 79.5% apply the recording of objective data. 61.5% apply the recording of nursing diagnoses. 61.5% plan the nursing activities in the nursing records. 56.4% make nursing notes by applying SOAPIER. 56.4% record the evaluation of nursing interventions based on the evolution of the patient's condition. 62.8% apply the recording of the re-evaluation of nursing interventions based on the evolution of the patient's condition. Conclusions: The use of the SOAPIER format is evident, which reflects that during the academic training the Nursing Care Process has been implemented and how to capture it through this record based on scientific evidence.
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在护理职业轮转实习生中使用SOAPIER格式
简介:SOAPIER格式是一个系统结构,用于记录和解释患者应该得到的问题和护理。目的:确定在安巴托技术大学护理职业轮转实习生中SOAPIER格式的使用。方法:采用横断面定量描述方法进行研究。样本包括78名轮岗囚犯;采用修改后的问卷,经专家验证,Cronbach’s Alpha值为0.811,保证了仪器的可靠性。结果:75.6%采用主观数据记录,79.5%采用客观数据记录。61.5%采用护理诊断记录。61.5%在护理记录中计划护理活动。56.4%的人使用肥皂皂制作护理笔记。56.4%的医生记录了根据患者病情演变对护理干预措施的评价。62.8%的护士根据病情的变化,对护理干预措施进行重新评估。结论:SOAPIER格式的使用是显而易见的,这反映了在学术培训期间,护理过程已经实施,以及如何通过基于科学证据的记录来捕捉它。
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